*Bettina Claudia Balla1, András Terebessy2, Emese Tóth3, Pèter Balázs2
Hungarian high school students’ attitudes toward HPV vaccination
1School of Postdoctoral Studies, Semmelweis University, Budapest, Hungary
Director: prof. Károly Rácz, MD, PhD, Dsc
2Institute of Public Health, Faculty of Medicine, Semmelweis University, Budapest, Hungary
Head of Faculty: prof. László Hunyadi, MD, PhD, DSc
3Faculty of Medicine, Semmelweis University, Budapest, Hungary
Head of Faculty: prof. László Hunyadi, MD, PhD, DSc
Introduction. On annual average, in a five year period (2008-2012) there died 407 women and 1490 new cases were diagnosed of cervical cancer in Hungary. The country’s screening program set up 2003 is available free of charge for all women aged 25-65.
Aim. Our study aimed to explore the knowledge and attitudes of senior high school girls (18/19 years) in Budapest about cervical cancer and toward the HPV vaccination.
Material and methods. 492 girls (52.6% of grammar and 47.3% of vocational schools) were selected randomly out of 12 facilities. They completed anonymously and voluntarily our self-administered questionnaire between April 2013, and May 2014. The survey of 54 matrix questions concerned basic socio-demographic and lifestyle factors and questions partly assessing the girls’ knowledge about cervical cancer partly testing their attitudes toward HPV vaccination and vaccination programs.
Results. 70.1% of the girls knew exactly the STD nature of HPV infection, however 9.8% heard never of the HPV vaccine. Their views about the vaccination were rather positive as 59.9% would make it compulsory, and 79.5% would have vaccinated their own future children too. Additionally, 63.2% of girls (among them the significant majority of vocational schools) would have vaccinated boys as well. More than two out of ten girls (23.1%) were already vaccinated. As for secondary prevention, 91.4% believed that the regular attending of cervical cancer screening was important.
Conclusions. The girls’ knowledge in our sample about cervical cancer and the HPV vaccination proved to be substandard. Grammar schools girls had more thorough knowledge that increased their receptiveness of vaccination.
In Hungary, cervical cancer is the eight most common cause of female cancer mortality and was the second among cause related malignant morbidity rates of women aged 15-44 in 2009-2012. The mortality rate was 6.23/100 000 in 2012, which exceeded three times the relevant EU-15 member states’ data. On average 407 women died annually of cervical cancer in 2008-2012 and around 1490 new cases became diagnosed every year (1). Even though numbers seem to be unchanged, from 2001 to 2010 the standardised early incidence (25-64 years of age) had gradually dropped from slightly above 35/100 000 to around 25/100 000 (2).
Hungary’s national cervical cancer screening program available for all women aged 25-65 was established in 2003. This target group is invited to screening every three years by postal letters. However, attendance rates were far from optimal level in the initial years. In 2007 it was estimated to be only 24.3% (3).
Cervical cancer is due to human papillomavirus (HPV) infection. The worldwide HPV prevalence is above 99% among cervical cancer patients (4). This DNA virus has more than 200 known serotypes (5, 6), forty of those can infect the epithelium of the perineal region (7, 8). Types 16, 18, 31, 33, 35, 45 are carcinogenic thus „high-risk” (HR) sexually transmitted HPVs, while others, like types 6 and 11 are „low-risk”(LR) ones. 70% of cervical cancers are caused by HR-HPV types 16 and 18 (9), and 90% of genital warts are caused by LR-HPV types 6 and 11 (10, 11). Infection of carcinogenic serotypes is usually of transitory nature. The clearance of the infection is about 12-18 months in general (12). The peak of prevalence of transitory HPV infections is in the late teens and early 20s, usually after entering sexual activity (4, 13, 14, 15, 17). 10% of HR-HPV infections are persisting for several years and may develop precancerous lesions. The peak of prevalence of these lesions is in the 30s and it takes about 5-10 years to change for invasive cancers with a maximum of prevalence between 40-50 years of age (18-20).
Actually, there are two HPV vaccines available on the pharmaceutical market. Both are recombinant, assembled from virus-like particles (VLP) of the L1 capsid protein. The quadrivalent Gardasil (Merck), protecting against serotypes 6, 11, 16 and 18 was introduced in the European Union since December 2006. The bivalent Cervarix (GlaxoSmithKline), protecting against serotypes 6 and 11 is available since July 2007 (22, 23). The US Food and Drug Administration approved in 2009 the HPV vaccine also for males of 9-25 years, identical with the age group of females. The aim of males’ vaccination is to decrease the number of genital warts, anal and penile cancers (23).
Among the EU-27 member states, alongside with Norway and Iceland, 20 countries have established the HPV vaccination program. In all countries – expect for Austria, where boys are also included – regular vaccination is proposed to girls from 9-18 and catch up vaccination for women from 12-40 (24). Since 2009, around 300 Hungarian municipalities decided to participate in the HPV vaccination by partial or total public financing of the vaccine for underage and young adult females. From September 1, 2014 two doses of the Cervarix vaccine are recommended and available free of charge for 12-13 year old schoolgirls in Hungary as a part of the optional school vaccination program (25). As a result, the program has achieved by 2014 the vaccination rate above 80% in the target population (26).
In our study, we explored the attitudes toward the HPV vaccine and the knowledge of cervical cancer among high school senior girls in Budapest. Data obtained could predict their future participation in screening programs and their receptiveness toward HPV vaccination (27). Additionally, blanks in their knowledge may indicate the weak points of the Hungarian health education programmes. Our decision for high school seniors of 18-19 years was adjusted to the average age (17.3 years) of the first sexual intercourse in Hungary according to the Global Sex Survey Report (16). The prevalence of HPV infection is the highest in this age group (16) member of which enter also the age of starting a family.
Material and methods
Based on the Ministry of Education’s online databank of the middle schools, we selected randomly 12 high schools in the Hungarian capital between March 2013 and May 2014 (28). First we contacted them via email and when the principals’ approval was obtained, we distributed 670 questionnaires among the 18 years old girls who filled them out during the biology class or the class master’s session. Given that these girls were not underage, we did not need their parents’ consent. The questionnaire and the method of data sampling procedure were reviewed and approved by the institutional board of ethics of the Semmelweis University (reference number: 32/2013). All questionnaires were administered anonymously and voluntarily without any incentives.
The questionnaire contained 54 matrix questions of which 26 concerned basic demographic, socio-economic and lifestyle factors, 13 tested the knowledge about the HPV infection and cervical cancer, 11 the information about HPV vaccine and 4 the screening of cervical cancer. The response rate was 73.44% (n = 492). All „I don’t know” answers were added to the no reply options. After data processing, we used the IBM-SPSS 21.0 program to explore frequencies and analyse associations by Pearson Chi-square test and binary logistic regression at a significance level of p < 0.05.
Socio-demographic background and lifestyle factors
233 girls (47.4%) studied in grammar schools and 259 (52.6%) in vocational schools representing equally both school types. 66.2% of girls lived in Budapest, others rented an apartment, lived in a school’s dormitory or were daily commuters to the capital from the suburbs. The majority (87%) had siblings and 12.3% had a mother employed in the health service. The fathers’ proportion employed in the health service was only 1.6%. Religious affiliation was admitted in 25%. Atheism was indicated in 19.5% while 13.8% were undecided in religious matters. The overwhelming majority (73.1%) followed no special diet but only 50.3% dined regularly at the same time of the day. 83.3% exercised regularly or occasionally, from light jogging to rigorous physical activity. As for unhealthy habits, 28.8% of the girls were smoking tobacco (tab. 1).
Table 1. Basic socio-demographic and lifestyle factors of the sample (n = 492).
|Variables||Proportions in %|
|Number of siblings (n = 492):|
none (n = 64)
one (n = 228)
two or more (n = 200)
|Perception of family’s income (n = 484):|
good (n = 103)
average (n = 311)
below average (n = 70)
|Religious affiliation (n = 287):|
religious (n = 123)
atheist (n = 96)
indecisive (n = 68)
|Attitude toward marriage (n = 479):|
positive (n = 357)
negative (n = 43)
indecisive (n = 79)
|Time of giving birth to first child (n = 444):|
before the age of 25 (n = 189)
after the age of 25 (n = 227)
no plans for childbearing (n = 28)
|Internet usage (n = 490):|
constantly online (n = 70)
2-3 hours/day (n = 255)
1 h/day or less (n = 165)
Attitudes toward vaccines in general
To the general question about vaccination programmes, 63.1% indicated that compulsory vaccines were important. The attitude toward recommended vaccination was markedly different, thus only 16.4% would accept this option. The main reason for 83.6% rejection was a negative concern about efficacy. As for family background, 16.4% of the girls had experienced supportive attitudes by family members toward recommended vaccination (tab. 2). Concerning the origin of their knowledge, girls gained information more likely from friends and family members (37%) and via Internet (30.1%), than from distinct medical professionals (24.6% gynaecologist, 19.5% GP and 15.9% district nurse). Television and radio programs were source of information in 22.4%.
Table 2. Receptiveness toward and rejection of vaccines.
|Type of vaccination||Receptive with high importance (%)||Receptive with minor importance (%)||Rejected (%)|
Knowledge about cervical cancer and attitudes towards the HPV vaccine
Only 33.7% of the girls knew that cervical cancer was caused by infection. Nevertheless, the majority (74.7%) marked HPV as a possible causative agent. Thus they did either not conceived that „V” of the acronym „HPV” stood for a virus, or they ignored the viral origin of the cervical cancer. Significantly more girls knew in grammar schools than vocational schools that the partner’s promiscuity could also be a risk factor (tab. 3).
Table 3. Girls’ knowledge about cervical cancer and its risk factors in grammar and vocational schools.
|Variables||Grammar schools (%)||Vocational schools (%)||p-value|
|Cervical cancer is due to infection||33.5||66.5||34||66||0.906|
|HPV infection is an STD||72.1||27.9||68.3||31.7||0.363|
|Promiscuity is a risk factor||64.8||35.2||56.4||43.6||0.056|
|Partner’s promiscuity is a risk factor||45.9||54.1||33.6||88.4||0.005|
|Unprotected sex is a risk factor||57.9||42.1||49.8||50.2||0.071|
About the possible ways of prevention, the overwhelming majority (98.4%) believed that attending cervical cancer screening was important. When asking them about possible reasons for the low attendance rates, 41.1% marked uncompensated losses in time and money, 31.1% indicated lack of motivation, 28.9% shame, and 22.8% unfriendly circumstances, finally 21.7% mentioned fear of pain by the examination.
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