Sex Disabil (2010) 28:245–253

DOI 10.1007/s11195-010-9172-6

ORIGINAL PAPER

Awareness of Turkish Nursing Students About Risk

Factors for Cervical Cancer and Prophylactic Human
Papillomavirus Vaccine

Fatma Tas • Aysegul Isler • Figen Isik Esenay • Sadik Aksit •

Zumrut Basbakkal

Published online: 9 July 2010

Ó Springer Science+Business Media, LLC 2010

Abstract The aim of this study was to evaluate nursing students’ knowledge about risk
factors for cervical cancer and prophylactic HPV vaccine. The nursing students in a
nursing school in Turkey were asked to complete a self administered questionnaire eval-
uating the knowledge of students regarding STDs, cervical cancer and HPV vaccine. From
a total of 650 female nursing students, 400 agreed to fill in the questionnaire. While 98% of
the students defined HIV infection as STD, only 37% of them indicated that HPV is one of
the STDs. About one-third of the students reported that HPV is a risk factor for the cervical
cancer. Only 16% of the students had heard of HPV vaccine for the prevention of cervical
cancer. Most of the students had no sexual intercourse before. In conclusion, nursing
students’ knowledge especially on the association of HPV and cervical cancer is not
satisfactory.

Keywords Human papillomavirus vaccine
Nursing students
Turkey

Introduction

Cervical cancer is the second most common cancer among women next to breast cancer,
and is the primary cause of cancer-related deaths in developing countries [1–3].
F. Tas
Faculty of Health Science Nursing Department, Selcuk University, Konya, Turkey

A. Isler (&)
Department of Pediatric Nursing, Akdeniz University Antalya School of Health, Antalya, Turkey
e-mail: gulisler@yahoo.com

F. I. Esenay
Mersin University School of Health, Mersin, Turkey

S. Aksit
Social Pediatric Department, Ege University Faculty of Medicine, Izmir, Turkey

Z. Basbakkal
Pediatric Nursing Department, Ege University School of Nursing, Izmir, Turkey

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According to the Globocan study carried out by the International Agency for Research
on Cancer in 2002, cervical cancer is diagnosed in about 500,000 women globally and is
responsible for more than 280,000 deaths annually [2]. Although reliable data on cancer
mortality in Turkey are lacking, annual crude incidence of cervix cancer is estimated 4.5
per 100,000 women, with mortality rate 2.1 deaths per 100,000 women on the same
report [2].
The Human Papillomavirus (HPV) infection is one of the most common Sexually
Transmitted Diseases (STDs) worldwide [4]. HPV is a critical risk factor for developing
cervical cancer [1]. Other possible risk factors include smoking, Human Immunodeficiency
Virus (HIV) infection, co-infection with Chlamydia, poor diet, oral contraceptives, mul-
tiple pregnancies, low socioeconomic status, in utero exposure to diethylstilbestrol medi-
cation, and family history of cervical cancer [4–7]. Risk factors that predispose someone to
acquire HPV include high-risk sexual behaviors, sex at an early age, many sexual partners,
and sex with uncircumcised males.
Cervical cancer is a preventable disease. In the past, regular pap tests were the best way
to prevent cervical cancer by detecting and treating pre-cancerous cell changes before they
develop into cancer. After understanding the relationship between HPV infection and
cervical cancer, prophylactic HPV vaccines have been developed for the prevention of
cervical cancer. Administering the vaccine to girls and young women before they are
infected by HPV will reduce their risk of cervical cancer. Two subunit HPV vaccines are
currently on the market and have been used in many developed countries. Current literature
showed that both vaccines are safe and effective for preventing persistent HPV infection
and HPV-associated diseases by 90–100% [8].
To the best of our knowledge, there is not yet a study in our country, assessing the
knowledge of health professionals and nursing students on the risk factors for the
development of cervical cancer and the awareness of prophylactic HPV vaccine. The
evaluation and the elimination of the possible knowledge deficits about STDs of the
nursing students as the future medical personnel are very important. The aim of the study
was therefore to evaluate nursing students’ knowledge regarding risk factors for the
development of cervical cancer and the awareness of the prophylactic HPV vaccine in
Turkey.

Research Questions

The research questions explored in this study were as follows:

1. What is the students’ level of knowledge regarding risk factors for the development of
cervical cancer?
2. What is the students’ awareness of the prophylactic HPV vaccine?

Methods

This cross-sectional study was carried out in a nursing school in Turkey. The aim of the
study was therefore to evaluate nursing students’ knowledge regarding risk factors for the
development of cervical cancer and the awareness of the prophylactic HPV vaccine in
Turkey.

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Sample

This study was conducted in a nursing school in Turkey. This school is a bachelor’s in
nursing program. There were a total of 650 female nursing students at the nursing school.
Of them, 400 students (61%) volunteered to participate in the study. Twenty-seven percent
of the students were studying in grade one while 17% in grade two, 29% in grade three and
26% in grade four.

Materials

A questionnaire developed by the researchers was used in data collection. A 36-item

questionnaire was used to obtain socio-demographic characteristics (8 items) and to assess
the knowledge of students regarding STDs, risk factors and prevention of cervical cancer,
HPV vaccine, and safe sexual behaviors (28 items). Answering the questionnaire took
approximately 20 min.

Method of Data Processing

The data were analyzed using the Statistical Package of the Social Sciences version 16.0
(SPSS Inc., Chicago, IL). The chi-square test was used for the comparison of categorical
variables. A p value less than 0.05 was accepted as statistically significant.

Ethical Considerations and Aspects

The legal permission to conduct the research was taken from the school ethics committee.
Prior to the implementation the students were given information about the study. A
comfortable and quiet environment was provided for the students to complete the
questionnaire.

Results

Demographic characteristics of the study population are given in Table 1. The age of the
students ranged from 18 to 32 years and the mean age of them was 21.5 ± 1.7 years
(Table 1). Almost all (99%) of the students were unmarried. About half (51%) of the
families of the students were living in the Aegean region and 52% of their families were
living in the rural area. While 55% of the nursing students were living at home (together
with their family or friends), 45% were living in the dormitory. Seventeen percent of the
students were smoking cigarettes.
Human immunodeficiency virus (98%), Syphilis (97%), HPV (64%) and Chlamydia
(56%) infections were well known STDs by the 4th grade nursing students. However, when
all students were evaluated for the awareness of STDs, HIV (97%) infection was the most
known STD, while HPV (37%) and Chlamydia (36%) infections were the least known
STDs As the grade levels of the students increased, the level of awareness of them about
STDs were proportionately increased (P \ 0.05). However, a great number of nursing
students (63% of all students and 36% of 4th grade students) indicated that they had never
heard of HPV. The knowledge scores of the students about other risk factors for cervical
cancer such as early sexual intercourse, number of sexual partners and oral contraceptive
use did not significantly change with the increasing grade level (Fig. 1).

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Table 1 Demographics charac-

Characteristics n %
teristics of students (N = 400)
Age (years)
18–20 123 30.8
21–23 237 59.2
[24 40 10.0
Grade
1 109 27.2
2 70 17.5
3 117 29.3
4 104 26.0
Marital status
Married 3 0.8
Single 397 99.2
Region of living family
Aegean 204 51.0
Marmara 64 16.0
Mediterranean 53 13.3
Central Anatolia 39 9.8
Black sea 25 6.2
East and Southeast Anatolia 15 3.7
Living place of the family
Rural 209 52.3
Town 133 33.3
Village 58 14.5
Economic status of family
Upper 6 1.5
Middle 371 92.8
Lower 23 5.7
Accommodation
At home 218 54.5
At dormitory 182 45.5
Smoke cigarettes
No 332 83.0
Yes 68 17.0

Awareness of the prophylactic HPV vaccine among students was generally very low.
Although it was significantly increased with an increasing grade level (P \ 0.05), it
reached only to 27% at the 4th grade (Fig. 2).
Sexual behaviors of the female nursing students are shown in Table 2. Most of the
students (94.5%) had no sexual intercourse before. The other 22 students were older than
16 years at the first sexual experience. Three of these 22 students were married. The
mean age of 19 single female students at the first sexual intercourse was
19.7 ± 1.7 years. Eight students reported that she was using oral contraceptive, but
interestingly, none of them had sexual experience. Six students had a Pap test before.
One of these 6 students was married.

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Don't know Know

100

90

80

70

60
Percent

50

40

30

20

10

0
1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 Grade
Partners’s multiple sexual activity
Number of sexual partnes
Early sexual intercourse

Oral contraceptive use

Chlamydia
Smoke

HPV
HSV
HIV

Fig. 1 Risk factors for development of cervical cancer reported by nursing students according to their grade

Fig. 2 Awareness of HPV

vaccine among nursing students
according to their grade

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Table 2 Sexual behaviors of

n %
female nursing students
(N = 400)
Previous sexual intercourse
0 378 94.5
1 15 3.7
[2 7 1.8
Age at first sexual intercourse (years)
17–19 9 2.2
C20 13 3.3
Never had sexual intercourse 378 94.5
Number of sexual partners in past year
0 380 95.0
1 17 4.5
2 2 0.5
Oral contraceptive use
Yes 8 2.0
No 392 98.0
Pap smear
Yes 6 1.5
No 394 98.5

Discussion

Although there have been several studies on the sexual behaviors and knowledge about
STDs among high school and university students in Turkey in the past [9–11], this is the
first study to evaluate nursing students’ knowledge regarding risk factors for cervical
cancer and the awareness of prophylactic HPV vaccine in our country. The authors were
surprised to find that the participating female nursing students demonstrated relatively low
knowledge levels for what one would expect for nursing students to know HPV as the
primary factor for cervical cancer. When we considered the whole study population, HPV
(37%) was the second least known STD next to chlamydia. However, 97% of the students
indicated that HIV infection as a risk factor for cervical cancer. This condition might stem
from that HIV is frequently debated in the media. The awareness of HPV reached to 64%
among last grade nursing students, whereas more of them are expected to know the
association of HPV and cervical cancer in order to counsel future patients. The results in
our study are generally comparable to many studies in different countries in the world. In
2005, Denny-Smith and colleagues carried out a survey on 240 female nursing students’
knowledge, health beliefs, perceptions of risk, and risk behaviors regarding HPV and
cervical cancer. They reported that female nursing students have a fairly low knowledge
level, low perceived susceptibility, and low perceived seriousness regarding HPV and
cervical cancer [12]. In another study conducted on STD knowledge by Lambert et al., in
2001, only 45% of the physician assistant and psychology students attending a private
college in upstate New York answered HPV questions correctly [13]. In a previous study
carried out by Yacobi and colleagues in 1999, the authors reported that only 37% of 289
university students in Florida had ever heard of HPV [14]. In another study evaluating
sexual knowledge, attitudes, and risk behaviors of students in Ege University, Turkey,
knowledge on STDs of the students were insufficient [11]. The most widely known STD

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was HIV infection. In 2007, Aras and colleagues published a study evaluating the sexual
attitudes and behaviors of university students in the same city and reported that HIV (90%)
and HSV (7%) were the most and least known infections respectively among the ques-
tioned STDs [9]. However, in the mentioned study, HPV had not been even placed among
STDs in the Questionnaire by the authors. The results of the study by Jacobi et al., suggest
that students who are at greatest risk of HPV infection are also the least knowledgeable
about this disease [14]. Thus, increasing the knowledge of HPV especially among students
as well as in the whole population is of paramount importance in the primary prevention of
HPV infection and cervical cancer.
Human papillomavirus has been recognized as the necessary cause of cervical cancer.
The nursing students in our study gave more satisfactory answers about other cofactors for
cervical cancer, such as cigarette smoking, early sexual intercourse and number of sexual
partners except oral contraceptive use (Fig. 1). In the study by Philips et al., young women
indicated smoking (49%), early sexual intercourse (56%), multiple sexual partners (79%)
and oral contraceptive use (48%) as cervical cancer risk factors [15]. Likewise, in the
literature, women’s knowledge about HPV and other cervical cancer risk factors has been
reported to be low [6, 14, 16–19].
To the question ‘‘is there a vaccine to prevent cervical cancer?’’, only 16.5% of the
nursing students answered ‘‘yes’’ ranging from 6.4% in grade 1–26.9% in grade 4 in our
study. Such a low awareness of prophylactic HPV vaccine among nursing students was
probably due to the timing of the study, i.e., before HPV vaccine license, in our country.
Nganwai and colleagues recently reported that 39% of the working nurses had information
about HPV vaccine to prevent cervical cancer [20]. In a recent study of Allen and col-
leagues, 82% of the college students were aware of HPV vaccine in the prevention of
cervical cancer [21]. However, Sait reported that only 9.8% of the patients applying
outpatient clinic in Saudi Arabia were aware of HPV vaccine [22].
The rate of adolescents who had sexual experience was 62% in Jamaica [23], 33% in
Ethiopia [24], 43% in boys and 23% in girls in Nigeria [25], 44% in boys and 47% in girls
in Sweden [26]. The mean age of first sexual intercourse is 15.8 years in the USA,
16.2 years in Germany and 16.8 years in France [27]. The rate of adolescents with intel-
lectual disability who had sexual experience was 30% of adolescents had experienced
kissing, 3.3% of them had sexual intercourse in Turkey [28]. In our study, both the rate of
female university students with sexual experience seem to be lower and mean age of first
sexual intercourse higher as compared to many industrial countries. Most of the female
nursing students (94.5%) in our study had no sexual intercourse before. The other 22
students were 17 years or older at the first sexual experience. Three of these 22 students
were married. The mean age of 19 single female students at the first sexual intercourse was
19.7 ± 1.7 years. Our results are comparable to the previous studies carried out among
university students in our country. The rates of college female students with sexual
experience have been reported between 5% and 25% in Turkey [10]. In a study carried out
among university students in Izmir, Turkey, the mean age of first sexual experience of
female students was reported as 16.5 ± 0.8 years [10]. In another study by the same
authors in Izmir, the rate of sexual experience among new students entering a university
was higher in boys (57%) than in girls (5%) [10]. Although some studies [12] suggested
that there is a relationship between awareness of STDs and safer sexual behavior, con-
siderable differences in the rate of sexual experience between boys and girls in Turkey
cannot be explained solely by awareness of STDs and cervical cancer. In a previous study
carried out among university students in Turkey, the most important two factors

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influencing the sexual attitudes and behaviors reported by the female students were ‘the
need to protect virginity’ and ‘the expectations of families’ [9].
In our study, we were surprised to see that only six students had a Pap test before. One
of these 6 students was married. In a study carried out by Denny-Smith et al. 96% of the
nursing students have had a pap test before [12], as compared to 5.5% of female nursing
students found in our study. Findings of such as the lower rate of Pap test might stem from
a low rate of sexual intercourse among our students and relatively insensitive attitude to
sexual health. American Cancer Society (2008) and the American College of Obstetricians
and Gynecologists (2008) recommend that all women should receive their first gynecologic
visit for health screening, guidance, and prevention measures before their first sexual
encounter, ideally between the ages of 13–15 years, and have their first Pap screening
about 3 years after they begin having vaginal intercourse but no later than age 21 [5].
The results of this study have mainly two limitations. First, very low sexual intercourse
rate in female nursing students found in our study may be due to the problem of self-report
bias. Female students may have under-reported their sexual activity because of the
emphasis on virginity in traditional Turkish society, even they were assured about privacy
of their answers. Second, because there were only a small number of students with past
sexual experience and having had a Pap test, we could not build a logistic regression model
to analyze that which factors influence risky or safer sexual behaviors.

Conclusions

Early sexual intercourse does not currently seem to be an important problem in female
nursing students in Turkey despite their relatively insufficient knowledge about the most
common STDs and the risk factors and prevention of cervical cancer. Furthermore,
absence of sexual activity may be due to the efforts to protect their virginity in the
premarital period in traditional Turkish society. Therefore, nursing students as future
health care providers must be given more information about STDs, cervical cancer and safe
sexual health during their education in order to be able to counsel correctly future patients.

Acknowledgments This study received external funding from Akdeniz University Scientific Research
Project Unit.

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