International Journal of Medical Science and Current Research (IJMSCR) Available online at: www.ijmscr.com
Volume2, Issue 4, Page No: 19-29 July-August 2019
19
Medicine ID-101739732
A Survey of the Awareness of the HPV Vaccine and Cervical Cancer among High School
Females and Parents in Saudi Arabia
Reema Al-Rasheed1*, Reem Labani1*, Al-Waleed Babiker2, Tawfeq Al-Andejani1, Nouf Al-Masoud1 1
College of Medicine, 2 Departments of Obstetrics & Gynecology King Khalid University Hospital, Riyadh, Saudi Arabia
*Corresponding Author:
Reema Al-Rasheed College of Medicine
King Khalid University Hospital, Riyadh, Saudi Arabia
Type of Publication: Original Research Paper Conflicts of Interest: Nil
ABSTRACT Background:
The HPV (Human Papillomavirus) is a definitive cause of cervical cancer. It is well known that HPV vaccination prevents the development of cervical cancer by almost 100%. Objectives: To conduct a comparative survey of the awareness of the HPV vaccine among high-school female students and parents and to compare their willingness to obtain the HPV vaccine. As well as determining the factors which influence both the acceptance and the refusal of the HPV vaccine? Design: This survey was conducted as part of a convenient cross-sectional study. Setting:King Khalid university hospital as well as various high schools in Riyadh, Saudi Arabia. Methods: The subjects were handed a self-administered questionnaire.Main outcomes: The questionnaires determined: 1) The level of awareness of HPV infection among female high school students, (2) cervical cancer and the role of vaccination, and (3) the factors which influenced either the acceptance or the refusal of the vaccine.Results: The study included 412 female high school students and 253 parents. A general level of cervical cancer awareness among parents and high school students was noted in (76.7%) and (49.3%) of the study subjects, respectively. However, only a few of them identified HPV infection as being a cause of cervical cancer. These were (16.6%), (7.5%), respectively. The main source of information was the internet (39.9%), (26.5%), followed by doctors amo ng the parents questioned (15.8%), and by schools among the students questioned (7.3%). The majority in both groups (78.3% and 76%) stated their willingness to get vaccinated after knowing that it can prevent cervical cancer, and most of them (82.2% and 79.9%) agreed to vaccinate their daughters, too. The barriers against HPV vaccination among parents and high school students were: (1) a general lack of knowledge about the vaccination (61.1% and 60.6%) as well as (2) uncertainty surrounding its safety (24.1% and 20.2%), respectively. The only factor, which was statistically significant in affecting the awareness level was marital status (p=0.007); however, it did not affect the attitude of subjects towards accepting the vaccination. Conclusion: Both groups showed a low level of awareness regarding the issues of cervical cancer, HPV, and vaccination. A lack of knowledge was identified as the primary reason to reject the vaccine, followed by uncertainty surrounding its safety among both parents and high school students. Hence, an educational awareness program should be established in the country, and we should target the community through social media in order to raise awareness of the issues of cervical cancer and the importance of vaccination.Limitations:The study was limited by including few male participants. Moreover, it would have been better to include more parents amongst the subjects surveyed.
Keywords: Human papillomavirus, HPV, vaccine, cervical cancer, awareness, , knowledge.
INTRODUCTION
Cervical cancer is the most common cancer in women worldwide; it accounts for 13% of all female cancers and is responsible for 85% of cancer deaths, in developing countries. In Saudi Arabia, cervical cancer is the 9th most common malignancy with a prevalence of 2.6% (1). Although HPV infection in many cases is resolved, if left untreated it tends to
occur more frequently and persistently, which may result in the manifestation of cervical cancer (2).
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increasing the chance of developing cervical cancer among young females (16, 18, 23).
In a study that was conducted in Al-Sharjah, it was concluded that 52.1% of the study subjects were aware of HPV vaccine availability (16). While another study carried out in the United Arab Emirates (UAE) revealed that only 28% of subjects recognized that the HPV vaccine was a preventive measure for cervical cancer (23). However, in a study which was conducted on Mozambican female adolescent
Such studies have explored the level of awareness of the HPV vaccine and cervical cancer, the role of vaccination, and the factors affecting both the refusal and the acceptance of HPV vaccination.
Such studies have succeeded in identifying the common barriers and factors involved in either accepting the HPV vaccine or refusing to take it.
Our research aims to help prevent the spread of cervical cancer and encourages the implementation of vaccine campaigns as well as various prevention programs that may help in the early recognition and prevention of cervical cancer.
Methods:
Studydesign and settings:
A cross-sectional study took place at King Khalid University Hospital (KKUH) and within several participating local schools in Riyadh, Saudi Arabia, during the month of February 2018.
Study Population and Sampling
The study involved 412 high school female students and 253 parents, who attended KKUH primary health care clinics. We included Saudis as well as non-Saudis who were living in Riyadh, Saudi Arabia, who agreed to participate in the study. Those who were not able to speak Arabic or English, medical students, or those unwilling to participate were all excluded from the study.
Study Instrument and Data Collection
Subjects were handled self-administered
questionnaire forms (paper-based for parents and in electronic form for female students). The content of the questionnaires were as follows: 1) verbal/written
informed consent of the subject, 2) their socio-demographic information (age, gender, nationality, education level, occupation, 3) their marital status, 4) economic status, 5) age when first married, their family size, and the gender of the various members of the family. ,6) the subject’s awareness and their knowledge of HPV, of cervical cancer, and the role of vaccination, as well as the factors affecting their acceptance, or their refusal of the HPV vaccine.
The section regarding the awareness of the HPV vaccine and cervical cancer required the subject to answer with either a “Yes” or a “No” response. The other questions were about the route of HPV transmission, the association between HPV and cervical cancer, and their current source of information. For parents, a question about their
preference regarding getting their daughters
vaccinated was also added.
This study has been approved by the Institutional Review Board at King Saud medical city.
Statistical Analysis
Data was analyzed by using the Statistical Package for Social Studies (SPSS® 22; IBM Corp., New York, NY, USA) for Windows®. Continuous variables were expressed as mean (standard deviation), and categorical variables were expressed as numbers and percentages. The t-test and one-way ANOVA test were used for continuous variables, whilst the Chi-square test was used for categorical variables. A p-value <0.05 was considered statistically significant.
Summary of the Results:
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individuals numbered (82.2%) and (79.9%),
respectively. The barriers against HPV vaccination among parents and high school students are shown in table-2. The only factor which was statistically
significant in affecting the awareness level was the subject’s marital status (p=0.007); however, it did not affect their attitude towards accepting the vaccination.
Table 1-A: Shows the baseline characteristics of parents in the survey.
Characteristics Number %
n= 253
Age 15-24 y 35 13.8
25-40 y 134 53.0
> 40 y 84 33.2
Gender Male 41 16.2
Female 212 83.8
Marital status married 238 94.1
divorced 15 5.9
Age when first married <18-year-old 96 37.9
18-25-year-old 107 42.3
>25-year-old 50 19.8
Number of children None 71 28.1
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>4 65 25.7
Number of female children
None 104 41.1
1-4 128 50.6
>4 21 8.3
Do you have an occupation?
Yes 110 43.5
No 143 56.5
Average monthly income
<5000 SR 33 13.0
5000-10000 50 19.8
>10000 56 22.1
Education level None 13 5.1
Primary 21 8.3
High school 72 28.5
Bachelor or higher 147 58.1
Table 1-B: Shows the baseline characteristics of the female high school students in the survey.
Characteristics Number %
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Age 15-24 y 398 96.60
25-40 y 8 1.94
> 40 y 6 1.46
Marital status Single 398 96.60
married 14 3.40
divorced 0 0.00
Age when first married.
Not married 398 96.60
<18-year-old 3 0.73
18-25-year-old 8 1.94
>25-year-old 3 0.73
Number of children None 399 96.84
1-4 13 3.16
>4 0 0.00
Number of female children
None 399 96.84
1-4 13 3.16
>4 0 0.00
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occupation? No 394 95.63
Average monthly income
<5000 SR 60 14.56
5000-10000 110 26.70
>10000 242 58.74
Table-2:
Barriers against vaccination Parents Student
Lack of knowledge 62% 63%
Safety concerns 25% 21%
Effectiveness concerns 9% 10%
Cost of vaccination 4% 6%
Graph-1
Results & Discussion:
Our study is the first study in Saudi Arabia, which aims to explore the factors influencing both parents and students regarding their willingness or refusal to take the HPV vaccine. The results from both of the groups surveyed were later compared with research studies from different countries.
Awareness of cervical cancer was higher in the parents’ group compared with the students’ group. These results were (76.7% and 50.7%), respectively. Results that were of a similar nature to the ones found in our study, (i.e. pertaining to the general level of awareness of HPV in the parents’ group) were presented in another study conducted in the
United Arab Emirates (16). A lower level of awareness was revealed, however, in a study done on women attending a tertiary care hospital in India (17). When comparing the level of awareness in the students’ group to Mozambican adolescent girls (84 %), our results were deemed to be very low. This could most likely be related to the ongoing health education program and health communication activities in the Mozambique region (18).
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study (35%, 82%) (16, 23). Moreover, Hungarian high-school students’ knowledge of HPV as a cause of cervical cancer was found to be 64%. This may perhaps be the case due to a resolution that was passed by the Hungarian government in 2014 to make the HPV vaccine mandatory among students aged 12-13-years-old (24).
Knowledge of the HP Virus as a cause of cervical cancer via sexual transmission in both groups.
The students’ group showed higher results than the parents’ group. Higher results were revealed in the UAE and Al-Sharjah when comparing the parent group results (23, 16). Students in the research carried out in Mozambique also revealed higher results than in our student group (71%) (18). In the Hungarian study mentioned earlier, the result was (52.1%) (24). these results may be high due to the same reason mentioned earlier.
The parents’ group showed higher results with regard to vaccine awareness and its availability than the students’ group (parents 13%, 14%), (students 15%, 17%), respectively. When comparing the Saudi parents’ group with the UAE and Al-Sharjah groups, our results were found to be lower (23, 16). The Mozambique students also had higher results than in our group (18). The availability of the vaccine was not asked about in any research that was conducted locally.
The main source of information in both the parents’ and the students’ group was the internet. The results for this category were (39.9% and 26.5%), respectively.
The research done in India, where the participants shared the same characteristics as our parents’ group revealed that their main source of information was from their neighbors, followed by the media (17). The research in Sharjah showed that the majority of information emanated from the TV, followed by school/university/ work, and lastly from the internet (16). Incidentally, the Mozambique students obtained their information from the HPV demo program (18). This demonstrates the effectiveness of educational programs that should perhaps be conducted more frequently on a local basis.
Barriers against taking the vaccine were mainly due to lack of knowledge, uncertainty surrounding its safety, and the vaccine’s overall effectiveness.
Another issue raised in the parents’ group was the cost of the vaccine itself. (61%, 24%, 9.3%, and 3.7%) as well as in the students group (60.6%, 20.2%, 9.1% and 6.1%). Additionally, both groups had similar results regarding taking the vaccine and giving it to their daughters (parents: 78.3%, 82.2%), (students: 76%, 79.9%). The participants who took part in the Al-Sharjah research revealed that the main barrier to taking the vaccine was that they thought they were too old to take it while others held the view that it was unsafe. However, the percentage of parents that would give the vaccine to their daughter tended to increase if the ministry had recommended the vaccination to parents (16). Malibari et al., (2018) concluded that the main concern was safety, but there were other barriers such as the side effects of the vaccine, and that it might encourage young women to engage in unlawful sexual encounters. Lastly, it was deemed by parents that it might not be effective (21). Both Polish and Canadian researchers stated that the decision of parents, as well as students, was likely to be greatly influenced by physicians (21, 27).
Among the parents’ group, the one independent factor that might have influenced the acceptance of the vaccine was ‘marital status’ in that it affected awareness but did not affect the willingness of subjects in obtaining the vaccine. No other factor was found to affect taking the vaccine in both groups. Similarly, in research conducted in the US, it was shown that the issue of marital status affected the level of awareness surrounding the HPV vaccine as well as the education level of the subjects. Moreover, different factors affecting the awareness of cervical cancer and HPV vaccines were reported, such as being a female, having female daughters, and being the parents of older children. All of these factors affected awareness levels positively. On the other hand, having uninsured children was found to affect awareness negatively (11).
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rejection of the vaccine was increased among people who had concerns about its safety (21). Research that was carried out in Canada showed that a positive attitude toward the vaccine was found in participants whose knowledge had been influenced by either doctors or health care workers. Young and those who lived in Atlantic Canada (27).
1. Sociodemographics of parents:
The baseline characteristics of parents are shown in table 1-a. A total of 253 Saudi parents participated in the study, these were mostly females 83.8% (N=212), who were married 94.1% (N=238), and were aged 25-40 years old 53% (N=134). , The age at which they first got married was from 18 to 25 years old (42.3%). The majority of such subjects had children 71.9% (N=182), with more than half of the participants having one or more daughters 58.9% (N=149). The percentage of occupied parents was 43.5% (N=110), with more than half of the parents having bachelor degrees or higher 58.1% (N=147), with an average income of more than 10,000 SAR 22.1% (N=56).
2. Sociodemographics of high school students:
The baseline characteristics of high school students are shown in table 1-b. More than 400 students participated in this study, almost all of whom were Saudi females 96.36% (N=397), aged mainly 15-24 years of age 96.6% (N=398), where the majority were single with only 3.40% (N=14) being married. The married subjects were aged approximately 18-25 57.1% (N=8), most of whom had female children 92.86% (N=13). The percentage of students who were working was 4.37% (N=18), with an average income of more than 10,000 SAR 58.74% (N=242).
3. Awareness of cervical cancer, HPV and vaccination among parents:
As graph 1 shows, most of the sample were aware of cervical cancer 76.7% (N=194), however, only a few recognized that the human papillomavirus (HPV) was a cause of cervical cancer 16.6% (N=42) and that the sexual route was the main source of transmission 14.2% (N=36). The majority remained unaware that vaccination against HPV can prevent cervical cancer 87% (N=220), and they knew little about its availability in Saudi hospitals 86.6% (N=219).
4. Awareness of cervical cancer among high school students:
As graph 1 shows, almost half of the female students surveyed were found to lack adequate knowledge of cervical cancer 50.7% (N=209). Moreover, they hardly knew that the human papillomavirus (HPV) was the cause of cervical cancer 7.5% (N=31) and that it is transmitted sexually 17.7% (N=73). As graph 2 shows, a huge number of participants did not recognize HPV vaccination as a preventive measure against cervical cancer 85% (N=350) and that it was available in Saudi hospitals 83.5% (N=344).
5. The sources of information among parents:
As shown in graph 3, the sources of information among parents are shown in graph 1. Surprisingly, the internet was the main contributor for conveying awareness of HPV to parents (N=101, 39.9%), followed by doctors (N=40,15.8%), and friends (N=37,14.6%). Unfortunately, school and parents were the least reported source of information 6.3% (N=16) ,2% (N=5), respectively.
6. The sources of information among high school students:
As shown in graph 4, the highest reported source of information among students was the internet 26.5% (N=109), then school 7.3% (N=109,), then friends 4.6% (N=19), with doctors and parents being the least reported sources for increasing awareness of HPV in young adult women. The percentages relating to these factors are 92.7% (N=11) and 2.2% (N=9), respectively.
7. Acceptance of the vaccination among parents:
The majority of the parents stated their willingness to get vaccinated after knowing that HPV vaccines can prevent cervical cancer 78.3% (N=198), and they were subsequently more willing to vaccinate their
daughters, too 82.2% (N=208). They also
acknowledged that the school curriculum should include information about cervical cancer in women 87.4% (N=221), with only a few parents rejecting the idea 12.6% (N=32).
8. Acceptance of vaccination among high school students:
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female daughters. They agreed to do this based on the knowledge that the vaccine might prevent cervical cancer. The percentages relating to this are 76%(N=313), 79.9%(N=329), respectively. Most of them stated that the school curriculum should contain information about cervical cancer 89.1% (N=367).
9. Barriers against vaccination among parents:
Graph 5 demonstrates that the barrier for parents to vaccinate themselves and their female daughters were the following: 1) lack of knowledge about the vaccine 61.1% (N=33), 2) uncertainty surrounding its safety 24.1% (N=13), 3) its effectiveness 9.3% (N=5), and 4) its cost 3.7% (N=2).
10.Barriers against vaccination among high school students:
Graph 6 demonstrates that the factors contributing towards the rejection of the vaccine among students were as follows: 1) lack of knowledge about the vaccine 60.6% (N=60), 2) concerns regarding its safety 20.2% (N=20), 3) its effectiveness 9.1% (N=9), and 4) its cost 6.1% (N=6).
11. Factors influencing the acceptance of vaccination among parents:
Multivariate analysis revealed that marital status affected the awareness of cervical cancer and HPV significantly (42 [2.88], P=0.007); however, it did not affect the attitude of subjects towards accepting the vaccination. As table 2 shows, subject age, gender, their age when first married , the number of children and female daughters, their occupation, their average income, and the educational level of the subject did not affect their acceptance of getting the vaccine.
12. Factors influencing the acceptance of vaccination among high school students:
Table 3 shows that, after analyzing the data, the subject’s age, their nationality, their marital status, the age when they first married , the number of children and female daughters they have, as well as the occupation of the subject, their average income, and their educational level were all not considered to be statistically significant.
Conclusion:
Both groups in this cross-sectional study showed a low level of awareness regarding cervical cancer,
HPV, and vaccination. A lack of knowledge was identified as the primary reason to reject the vaccine, followed by a feeling of uncertainty concerning its safety among both parents and high school students. Educational programs should be conducted more often in our country, and we should target our community through social media in order to raise awareness of the issue of cervical cancer and the importance of vaccination.
Recommendation:
Future studies should focus on including more male subjects. Any future study should include extra variables which may affect cervical cancer and the awareness level of HPV. We also recommend including more medical colleges in such studies in order to obtain a more realistic picture of the situation as well as more accurate knowledge regarding this issue. Such studies are also necessary in order to enhance the quality and accuracy of the end results so that we can have a better understanding of exactly what is happening within the Saudi population.
Conflict of interest:
None to declare.
Acknowledgments:
We acknowledge the following medical student at King Saud University in Riyadh, Saudi Arabia, for their contribution towards the data collection:
We would like to acknowledge the valuable contribution of [e.g. Abdullah Al-Harbi], a medical student at King Saud University, for his contribution towards the data collection in this study.
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