INTRODUCTION:
Human papilloma virus infection is one
of the most common sexually transmitted infections of the reproductive tract.
Most sexually active individuals of both sexes are liable to get infected at
some point during their life by HPV and some may be repeatedly get infected.
Most of the infections clear up on their own and most pre-cancerous lesions
resolve spontaneously. The risk of HPV infection becoming chronic and the
progression of precancerous lesions to invasive cervical cancer remains
constant in all women. The time required to develop cervical cancer ranges
between 5 to 10 years in women with weakened immune system and 15 to 20 years
in women with normal immunity. Persistent infection with high risk human
papilloma virus (especially type 16) can cause cancer of the vulva, vagina,
anus, penis and oropharynx.
Worldwide, cervical cancer is the fourth
most frequent cancer in women with an estimated 530,000 new cases respresenting
7.5% of all female cancer deaths. Estimates suggest that more than 270,000
deaths occur due to cervical cancer every year and more than 85% of these occur
in less developed regions2.
In developed countries, programmes are
in place which enables women to get screened, making most precancerous lesions
identifiable at stages when they can easily be treated. Early treatment
prevents up to 80% of cervical cancers in these countries.
In developing countries, due to limited
access to effective screening, the disease is often not identifified until it
is further advanced and symptoms develop. In addition, prospects for treatment
of such late stage disease may be poor, resulting in a higher rate of deaths
from cervical cancer in these countries.
Currently, there are two types of HPV
vaccines available in the global market: Quadrivalent Gardasil TM and
Bivalent cervarix TM .The HPV vaccine has demonstrated high degrees
of efficacy with maximum clinical effictiveness and cost- effectiveness in the
target population of young adolescents, who are less likely to have been
previously exposed to high risk HPV genotypes. As these vaccines are highly
effective before exposure to HPV, current guide lines prioritize adolescent
girls as the primary target group for HPV vaccination5.
A
cross-sectional study was conducted by Krishna Kavitha Ramavath et.al (2013) on
knowledge and awareness of HPV Infection and Vaccination among urban
adolescents in India. A sample of 1000 adolescents girls were selected randomly
from secondary schools and colleges. Data were collected by using
questionnaires which included knowledge questions on cancer cervix and HPV
awareness. The study results showed that, participants had poor awareness about
HPV infection and vaccination7.
The
high mortality rate from cervical cancer globally (52%) could be reduced by
effective screening and treatment programmes. Even though it seems to be a
definitive intervention to control mortality from cervical cancer, HPV vaccine
implementation is still facing barriers of vaccine cost, acceptance and lack of
awareness4. Since, HPV vaccine has been the recent trend, programmes
are required for creating awareness regarding HPV associated diseases and
benefits of vaccination for adolescents. India is conducting many programmes
and publishing research articles to enrich the adolescent girls. Therefore, the
investigator felt the need to assess the knowledge and attitude of I year B.Sc
nursing students regarding HPV vaccination.
OBJECTIVES:
1. To assess the level of knowledge of I year
B.Sc. Nursing students with regard to HPV Vaccination.
2. To assess the attitude of I year B.Sc.
Nursing students with regard to HPV Vaccination.
3. To analyse the association between
knowledge and attitude of I year B.Sc. Nursing students about HPV Vaccination
with their selected demographic variables.
4. To determine the relationship between
knowledge and attitude of I year B.Sc. Nursing students; with regard to HPV
Vaccination.
HYPOTHESES:
H1: There will be significant association between the
knowledge of I year B.Sc. Nursing students with regard to HPV vaccination and
selected demographic variables.
H2: There will be significant association between the
attitude of I year B.Sc. Nursing students with regard to HPV vaccination and
selected demographic variables.
H3: There will be significant relationship between the
knowledge and attitude of I year B.Sc. Nursing students regarding HPV
Vaccination.
METHODOLOGY:
The
present study is conducted by using quantitative approach with descriptive
survey design at a selected college of nursing in Guntur district, Andhra
Pradesh. The target population for the present study are the females studying
in I year B.Sc nursing course. The female students studying in I year B.Sc
nursing course in the selected college of nursing are the accessible
population. A sample of 76 I year B.Sc nursing female students are selected by
using convenient sampling technique.
The
sample included the female I year B.Sc nursing students, in the age group of 17
years and above, studying in selected college of nursing, available at the time
of data collection and willing to participate in the study. Male I year B.Sc
nursing students are excluded from the study.
A
structured tool for collecting the data is developed by the investigator. The
tool consists of three sections- section A, section B, section C.
Section
A consists of questions on personal
and baseline characteristics of the subjects. Such as: Age, Religion, Occupation
of father, Occupation of mother, Previous knowledge on HPV vaccination, Source
of knowledge, Family history of Cancer Cervix, and Relationship with the family
members who suffered with Cancer Cervix.
Section
B consists of 35 knowledge items on all
the aspects of HPV vaccination. The items are closed ended multiple choice
questions. Each correct response is allotted a score ‘one’ and score ‘zero’ for
each incorrect response. Maximum score for section B is 35.
The
subjects who scored 17 or less in section B are considered as having
‘inadequate knowledge’; scored between 18 to 26 as having ‘moderate knowledge’
and scored between 27 to 35 as having ‘adequate knowledge’.
Section
C consists of 15 statements to assess
the attitude of Nursing students regarding HPV vaccination. Each attitude item
has three options. i.e. Agree, Disagree, No idea. There are 7 positive and 8
negative statements.
A
score “1” is allotted to the response “agree” to a positive statement and a
score “zero” is allotted for the response of “disagree” (or) “no idea”.
A
score “1” is allotted to the response “disagree” for a negative statement, and
a score “zero” is allotted to the responses of “agree” or “no idea”.
The
total score for attitude scale is 15. Based on the scores obtained in section C
the subjects are considered as having Unfavourable attitude (score of 0 to 7),
Moderately favourable attitude (scores of 8 to 11) and Favourable attitude
(scores of 12 to 15).
Content
Validity:
The
prepared tool along with the objectives of the study was submitted to three
subject experts in Obstetrics and Gynaecology. Among them, one is a doctor and
two are senior faculty in the field of OBG Nursing. The suggestions of the
experts are incorporated in the final tool.
Reliability:
The
reliability was established by using Test – retest method and Karl Pearson’s
correlation of coefficient is computed to find out the reliability. It is found
that, “r” value of knowledge items is 0.78, and attitude is 0.94. The obtained
score indicated that, the tool is highly reliable.
Pilot
study:
Pilot
study is conducted on 10 female nursing students. The participants have shown
interest to complete the tool. It took 20 minutes for them to complete the
entire tool and no difficulties are expressed by them. These subjects are not
included in the main study.
Ethical
Consideration:
Ethical
clearance is taken from the institutional ethical committee.
Data
Collection Procedure:
A
written permission is obtained from the Principal of College of Nursing, and
from the Co-ordinator of I year B.Sc. Nursing. The investigator informed the
sample about the purpose of the study and requested for their cooperation
during the study. Data are collected during the last week of February 2018. Totally
76 I year female B.Sc. (N) students have answered the questionnaire.
Plan
for Analysis:
The
data are planned and analysed based on objectives and hypothesis of the study
by using descriptive and inferential statistics.
Demographic
data is analysed by using Frequencies and Percentages.
Frequencies,
Percentages, Mean, Standard Deviation and Chi-Square tests are used to analyse
the knowledge of the respondents.
Frequencies,
Percentages, Mean, Standard Deviation and Chi-Square tests are used to analyse
the attitude of the respondents.
t-
test is computed to analyse the
relationship between knowledge and attitude of I year B.Sc. Nursing students
regarding HPV vaccination.
RESULTS:
Section-I
– Characteristics of The Study Sample.
Age:
out
of 76 I year B.sc (N) students, majority of respondents (43 i.e,56.57%) are in
the age group of 18 years, Followed by 27 (35.52%) who are in the age group of
19 years and 6 (7.89%) are in the age group of 17 years.
Religion:
Majority
of subjects (38 i.e. 50%) are Christians, followed by Hindus (36 i.e. 47.38%)
and Muslims (2 i.e.2.63%)
Occupation
of father:
When
it comes to the occupation of the father, more than 60% (46 i.e. 60.52%) of
fathers of I year B.sc (N) students are coolies, 14 (18.42%) fathers are
self-employed, and 13 (17.10%) fathers are not working.
Occupation
of mother:
Majority
of the mothers of I year B.sc (N) students are house wives (49 i.e. 64.47%),
followed by mothers who are coolies (16 i.e. 21.05%); working women (10 i.e.
13.15%) and self-employed (1 i.e. 1.31%).
Previous
knowledge about HPV vaccination:
Out
of 76 students, 43 (56. 57%) had previous knowledge on HPV vaccination and 33
(43.42%) did not have previous knowledge on HPV vaccination. Out of these 43
respondents, who had previous knowledge, 35 (81.35%) have learnt from their
teachers, followed by 5 (11.62%) who have learnt from the health professionals,
2 (4.65%) have learnt from newspapers, and 1 (2.34%) have learnt from the
television.
Family
history of cervical cancer:
Out
of 76 students, only 4 (5.26%) answered that their family members have suffered
with cervical cancer, and the family members of remaining 72 (94.74%) have no
history of cervical cancer. Out of these 4 respondents, who have the family
history of cervical cancer, 2 (50%) are aunts, 1 (25%) is sister, and 1 (25%)
is mother.
Section-II-
Knowledge About HPV Vaccination.
Out of 76 respondents, 53(69.75%) knew
that ‘Cervix is an internal genital organ of a female’. Thirty five
respondents (46.05%) knew that ‘abnormal unwanted proliferation of immature
cells are known as Cancer’. Half of the respondents (38 i.e. 50%) knew that
‘Cancer Cervix means the abnormal growth of Cervical cells which are capable of
spreading to other parts of the body’.
Only 9.21% of the respondents replied
that, ‘the Cancer Cervix usually starts in the transformation zone
(Squamo-columnar junction)’. Majority (45 i.e. 59.21%) of students knew that
‘women with multiple sexual partners are at high risk for developing Cancer
Cervix’. Twelve (15.79%) have answered correctly that ‘bleeding after sexual
intercourse in the most suggestive symptom of Cancer Cervix’. Twenty-two
(28.94%) knew that ‘pap smear is the screening test to detect Cancer Cervix’.
Most of the respondents (44 i.e. 57.89%)
knew that ‘the full form of HPV is Human Papilloma Virus’. More than 1/3rd
of the respondents (28 i.e. 36.84%) knew correctly that ‘HPV 16 and 18 are the
type of HPV virus, which lead to Cervical Cancer’. Only 23 (30.26%) answered
correctly that ‘both men and women are prone for getting HPV infection’.
Thirty-six (34.21%) respondents correctly knew that ‘HPV does not get
transmitted by sharing the toilets’.
More than half of the respondents (41 i.e.
53.94%) knew that ‘the purpose of giving HPV vaccine is to prevent Cancer Cervix’.
Nearly 1/3rd of respondents (25 i.e. 32.89%) knew that ‘HPV vaccine
is invented by Ian Frazer and Jian Zhou’. Twenty-five (32.89%) respondents have
answered that ‘currently 2 types of HPV vaccines are available in the world’.
Twenty-four (31.57%) respondents are aware that ‘2 types of HPV vaccines are
available in India’. Twenty-five (32.89%) knew correctly that ‘Gardasil and
Cervarix are the trade names of HPV Vaccines available in India’.
Thirty three respondents (43.42%) knew
that ‘both males and females can take HPV vaccine’. Only 20 respondents
(26.31%) knew that, ‘the HPV vaccine contains virus like particles with the
same outer protein as HPV’. Thirty-one respondents (40.76%) knew that
‘Quadrivalent vaccine gives protection against 4 serotypes’. Only 18
respondents (23.68%) are aware ‘that Gardasil is a Quadrivalent vaccine’. Eight
(10.54%) students knew that ‘Cervarix is a Bivalent vaccine’. Eighteen (23.68%)
knew that ‘Gardasil gives protection against Cervical Cancer and genital
warts’.
Twenty-six (34.22%) respondents knew that
‘by forming antibodies in the body, the HPV vaccine gives protection against
Cervical Cancer’. Only 11 respondents (14.47%) knew that ‘9 to 12 years is the
best age to give HP vaccine for girls’; 20 respondents (26.32%) knew that ‘HPV
vaccine can be given for females from 9 to 45 years’; 33 respondents (44.44%)
knew that the ‘HPV vaccine is available in the form of single dose vile and
pre-filled syringe’.
Thirty-four (44.74%) have answered that
‘HPV vaccine is administered intra-muscularly’. Twenty (31.58%) four answered
that ‘HPV vaccine is injected in deltoid muscles’. Twenty-nine (38.15%)
respondents correctly knew that ‘0.5ml is the dosage of HPV vaccine’.
Thirty-two (42.10%) respondents knew that
‘a minimum gap of 4 weeks should be there between the first dose and 2nd
dose of HPV vaccination’. Seventeen (23.38%) students knew correctly that ‘a
minimum of 24 weeks should be there between the 1st dose and 3rd
dose of HPV vaccination’. Twenty-eight (36.84%) respondents knew that, ‘12
weeks should be the minimum gap between the 2nd and 3rd
dose of HPV vaccination’.
Twenty-nine (38.18%) students knew that,
‘the pain in the injection site is the common side effect of HPV vaccine’. One
fourth (19 i.e. 25%) of the respondents knew correctly that, ‘the person should
sit (or) lie down for 15 minutes after HPV vaccination to avoid falls due to
fainting’. Twelve (15.78%) respondents knew that, ‘the women with the history
of hyper sensitivity to yeast should not take HPV vaccine’.
Table 1: The Mean Knowledge
Score Of The Sample With Standard Deviation N
= 76
|
S.
No.
|
Variables
|
Mean
|
Standard
Deviation
|
|
1.
|
Knowledge
|
13.15
|
3.3
|
The mean knowledge score of sample is
13.15 with the standard deviation 3.3.
Table 2: Distribution
Of Sample By Their Level Of Knowledge
N = 76
|
S.
No.
|
Level
of Knowledge
|
Frequency
|
Percentage
|
|
1.
2.
3.
|
Inadequate
Knowledge
Moderate
Knowledge
Adequate
Knowledge
|
72
4
0
|
94.74%
5.26%
0
|
The
values in the above table reveal that, majority of students have inadequate
knowledge (72 i.e. 94.74%); very negligible number of students have moderate
knowledge (4 i.e. 5.26%); none of the students have adequate knowledge.
Section-III-
Attitude On HPV Vaccination:
Positive
Statements:
With
regard to the statement: “Cancer Cervix is common among sexually active females”,
equal number of respondents have shown positive attitude by agreeing to the
statement (38 i.e. 50%) and negative attitude by disagreeing to the statement
(38 i.e. 50%).
Twenty-three
(30.26%) respondents have shown the positivity to the statement: “Monogamy
(being with single partner) lessens the chance of developing Cancer Cervix”,
whereas, majority of respondents (48 i.e. 63.16%) have shown negativity by
disagreeing to the statement and 5 (6.58%) of them have answered that they have
no idea.
Very
less number of respondents (11 i.e. 14.47%) have positive attitude to the
statement: “HPV vaccine can be given to lactating (feeding) mothers”, however
majority of respondents (45 i.e. 59.21%) have disagreed to the statement, and
20 (26.31%) of them said that, they have no idea.
Fifteen
(19.74%) respondents have agreed that, “Cervical HPV infection progresses to
Cervical Cancer only, when there is association of other risk factors”,
whereas, 22 (28.95%) have disagreed with the statement, and 39 (51.31%) have
answered that, they have no idea.
Twenty-seven
(35.53%) respondents have reacted positively to the statement: “HPV vaccine
does not give protection from all types of HP Virus” however, 33 (43.42%)
respondents have reacted negatively and 16 (21.05%) have no idea about the
same.
Nearly
half of the respondents (36 i.e. 47.38%) believed that, “It is better to give
HPV vaccine between 9 to 12 years of age”, but, 26 (34.21%) have disagreed to
the statement and 14 (18.42%) respondents have no idea about the same.
Thirty-two
(42.10%) respondents have agreed to the statement that “It is better to give
HPV vaccine before the first sexual intercourse”. Whereas, 39 (51.31%) have not
agreed to that statement and 5 (6.58%) said that they have no idea.
Negative
Statements:
Out
of 76, only 15 (19.74%) respondents have shown positive attitude by disagreeing
to the statement: “Good hygiene totally eliminates the risk of developing
Cancer Cervix”, 47 (61.84%) have shown negative attitude by agreeing with the
statement and 14 (18.42%) have said they have no idea.
Only
16 (21.05%) respondents believed positively to the statement: “HPV vaccine
leads to Cervical Cancer in immune suppressed females” by disagreeing to the
statement, 29 (38.16%) believed negatively to the statement by agreeing to that
and 31 (40.79%) respondents answered that they have no idea.
Forty
(52.63%) respondents have correctly disagreed to the statement: “HPV vaccine
causes death”, while 26 (34.21%) have shown their misperception by agreeing to
the statement and 10 (13.16%) have replied that they have no idea.
Twenty-two
out of 76 (28.95%) have shown the positive attitude by disagreeing to the
statement: “After HPV vaccination if woman found to be pregnant, she must be
aborted”, while 19 (25%) respondents have shown negative attitude by agreeing
to the statement, 35 (46.05%) have answered that they have no idea.
Thirty-one
(40.79%) respondents have shown correct opinion to the statement: “Woman who
has taken HPV vaccine, need not go for screening test for Cervical Cancer,
later in her life” by disagreeing to that. Whereas, 25 (32.89%) respondents
have shown wrong opinion by agreeing to the statement and 20 (26.32%) have no
idea about that.
Forty-three
(56.58%) respondents have positive attitude towards the statement: “Cancer
spreads from one person to another person” as they have disagreed to the
statement. While, 18 (23.68%) have negative attitude as they have agreed to the
statement, 15 (19.74%) said that they have no idea.
Fifty-one
(67.10%) respondents have disagreed to the statement: “Spending money on HPV
vaccine is a waste”and shown their positive attitude. However, 20 (26.32%)
respondents have shown their negative attitude by agreeing to the statement,
and 5 (6.58%) replied that they have no idea.
Twenty-five
(32.89%) respondents have disagreed to the statement: “HPV vaccine gives 100%
protection against Cervical Cancer”, showing that they have positive attitude.
Whereas, 41 (53.95%) respondents have agreed to the statement showing that they
have negative attitude and 10 (13.16%) respondents have replied that they have
no idea about that.
Table 3: The Mean
Attitude Score Of The Sample With Standard Deviation N = 76
|
S.
No.
|
Variables
|
Mean
|
Standard
Deviation
|
|
1.
|
Attitude
|
7.56
|
3.22
|
The
Mean attitude score of the sample is 7.56 with a Standard deviation of 3.22.
Table 4: Distribution
Of Sample By Their Type Of Attitude N=76
|
S.
No.
|
Level
of Knowledge
|
Frequency
|
Percentage
|
|
1.
2.
3.
|
Unfavourable
Attitude
Moderately
Favourable Attitude
Favourable
Attitude
|
54
22
0
|
71.05
%
28.94
%
0
|
The
above table shows that most of the respondents (54 i.e. 71.05%) have
unfavourable attitude towards HPV vaccination, while, 22 (28.94%) have
moderately favourable attitude, none of them have favourable attitude.
Section-IV:
Association Between The Knowledge And Attitude Of I Year B.Sc. Nursing Students
With The Selected Variables.
Null
Hypotheses Formulated for statistical purpose:
Ho1: There will be no significant association between the
knowledge of I year B.S.c nursing students with regard to HPV vaccination and
selected demographic variables.
Ho2: Association will not be a significant between the
attitude of I year B.S.c nursing students with regard to HPV vaccination
selected demographic variables.
Ho3: There will be no significant relationship between
the knowledge and attitude of I year B.S.c nursing students regarding HPV
vaccination.
Table-7
shows that, the calculated t-value is 3.75 which is greater than the table
value at 0.05 level of significance. This indicates that, there is significant
relationship between the knowledge and attitude of I year B.Sc. Nursing
students with regard to HPV vaccination. Hence, the researcher has rejected the
null hypothesis H03 and retained the research hypothesis H3.
DISCUSSION:
The
present study was conducted with an aim to assess the knowledge and attitude of
I yr BSc nursing students. The results revealed that Majority of I year B.Sc.
(N) Students are in age group of 18 years (43 i.e. 56.73/%) and half of the
students are Christians (38 i.e. 50%). This is supported by the study conducted
by Ganju A.et.al which revealed that majority of students (83.43%) were less
than 20 years and 96.5% of students were Christians.
In
the present study, students got the information from the teachers (35 i.e.
81.39%). The results of the study conducted by Ganju A.et.al among students are
contrary to results of the present study, where it was found that most of the
respondents(41.2%) got the information from mass media.
In
the present study Seventy two respondents out of 76 (94.74%) had inadequate
knowledge about HPV vaccination. Fifty four respondents (71.05%) had
unfavourable attitude. This is supported by the results of the study conducted
by wibisono.p.et.al which revealed that poor knowledge(32.7%) poor attitude
exist towards HPV vaccination, among the respondents.
Significant
association is found between the knowledge scores of Nursing students with
regard to HPV vaccination and their Age (χ2= 311.26), Previous
knowledge on HPV vaccination (χ2= 6.71), Family history of
Cancer Cervix (χ2 = 5.89) at 0.05 level of significance. The
results of the study conducted by wibisono.p.et.al are contrary to results of
the present study, where it was found that no statistically significant
relationship exist between variables and knowledge regarding HPV vaccination.
CONCLUSIONS:
·
Majority of the I year
B.Sc. (N) students have inadequate knowledge with regard to HPV vaccination.
·
Majority of I year
B.Sc. (N) students have shown unfavourable attitude towards the HPV
vaccination.
·
Significant
association is there between the knowledge of I year B.Sc. Nursing students
with regard to HPV vaccination and their Age, Previous knowledge about HPV
vaccine and Family history of Cancer Cervix.
·
There is no
significant association between the demographic variables and attitude of I
year B.Sc. nursing student with regard to HPV vaccination.
·
Significant
relationship is there between the knowledge and attitude of I year B.Sc.
Nursing students with regard to HPV vaccination.
REFERENCES:
1.
World health
organization,comprehensive cervical cancer control; guide to essential practice
2.
Weekly epidemiological
record 10 April 2009,84,117-132.http://www.who.int/wer.
3.
Cervical Cancer In
India. Available from http://soned.org/uploads/pdf/cervicalcancers.pdf
4.
Cervical cancer
screening with the HPV test and the pap test in women ages 30 and older.
Available from http://www.cdc.gov/cancer/hpv/pdf/hpv-brochure-eng.2010.pdf
5.
Cervical Cancer in
India and HPV vaccination. K.Karthigeyan. Indian journal of medical knowledge
and awareness of HPV infection and vaccination.
6.
A.Ganja Sunita et al
2017. Assessment of knowledge and attitude of medical and nursing students
towards screening for cervical carcinoma and HPV vaccination- International
Journal of Community Medicine And Public Health. 2017 - Nov/Vol.4, issue 11
page:4193.
7.
Krishna Kavita Ramavath
(2013) “Knowledge and Awareness ofHPV Infection And Vaccination Among Urban
Adolescents In India - The Journal of Obstetrics And Gynecology Of India. (2013
Jun 27); 63 (6):399-404.
8.
Yasmin Islam Jessica et
al “Knowledge of Cervical Cancer and HPV Vaccine in
Bangladeshi Women - BMC women’s Health 2018; 18:15. Available at www.ncbi.nim.nih.gov
9.
Saqer Ahmed et al.
“Knowledge and awareness about Cervical cancer and vaccine (HPV) among parents
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10.
Rashid Shazia
“Knowledge, awareness and attitude on HPV, HPV Vaccine and cervical cancer
among the college students in India - Journal PLOS (Peer reviewed open access scientific Journal), 2016 Nov
18.
=311.26), Previous knowledge about HPV vaccination(