Human Papillomavirus

Increasing knowledge of HPV and HPV vaccine through an educational documentary in PA

Human Papillomavirus (HPV) is the most common sexually transmitted infection causing cervical, oropharyngeal cancers and genital warts. In the United States (U.S.), it is estimated that one in four individuals are infected, with an additional 14 million new cases of HPV infections occurring annually. HPV contributes to 17,600 cancers in women and 9,300 cancers in men annually. HPV vaccine is the most effective way to protect against HPV related cancers. However, there is a lag in HPV vaccination. Effective tools to increase knowledge and HPV vaccination is vital in decreasing the prevalence, incidence and mortality from HPV infections. A quasi-experiment showed a statistically significant improvement in knowledge post-intervention utilizing an educational session that included viewing a documentary video. Future initiatives that include educational videos can be helpful in increasing knowledge and promote awareness.

Background

Human Papillomavirus (HPV) is a common virus that is associated with skin warts, anogenital, oropharyngeal and cervical cancer^1,2. In the United States (U.S.) alone, an estimated 79 million individuals are infected, with an additional 14 million new cases of HPV infections occurring yearly³. HPV contributes to 17,600 cancers in women and 9,300 cancers in men annually⁴. HPV vaccine is the most effective and safest protection against HPV related cancers. Although there is an increase in HPV vaccination since its introduction in 2006, it remains disproportionately low in comparison to other adolescent vaccines. Four out of ten adolescent girls, and six out of ten adolescent boys are unvaccinated against HPV, and are vulnerable to cancer⁵. About one in 100 sexually active adults in the U.S. has genital warts at any given time. The highest rate of new HPV infections is between the ages of 15-24 years old⁷. HPV is transmitted through skin to skin contact, mostly through sexual activity with an infected individual^1,2,3,4.

HPV Vaccine Recommendation

The CDC and Advisor Committee on Immunization Practices (ACIP) updated the HPV vaccine recommendation in October of 2016. The new recommendation is for 11 or 12-year-old boys and girls to receive two doses of HPV vaccine instead of three doses for individuals starting the vaccination series before the age of 15 years old. Vaccinations must be 6 to 12 months apart. Three doses are recommended for individuals starting the vaccination series on or after the 15th birthday, and for people with certain immunocompromising conditions^1,2,6. ACIP recommends female vaccination at aged 13 through 26; and for males aged 13 through 21 for persons without adequate vaccination in the past. Immunocompromised individuals, transgender adults, and males who are bisexual, transgender or who plan to have sex with other men are still recommended to get three doses up until the age of 26. Vaccination series can still be started at age 9^1,2,6. This change was recommended by the CDC and the ACIP after data showed that the antibody responses after two doses given at least 6 months apart to 9-14 years old was as good or even better than the three doses given to older adolescents and young adults. Ideally, vaccination should be administered prior to HPV exposure or before their first sexual encounter^1,2,6.

Barriers

According to CDC, missed clinical opportunities is the most important reason for the low HPV vaccine uptake. Other contributing factors to low HPV vaccinations include: health care providers hesitancy to promote and vaccinate due to knowledge gap, lack of overall knowledge of HPV leading to misinformation, discomfort of practitioners regarding sexual behaviors, cost, and concerns about safety and efficacy.
System barriers such as lack of tools to remind practitioners, time constraints are prominent contributing problems.^6,7. In the underserved populations, limited knowledge about the vaccine is more pronounced, cultural differences, insurance coverage and immigration status increased resistance to HPV vaccination⁸. Barriers to vaccination in the college students noted were side effects, costs, and lack of basic knowledge regarding HPV and HPV vaccination⁹.

Strategies

Strategies used to combat this public health threat includes effective education, implementation of tools such as the AFIX approach recommended by the CDC, reminder and recall systems, assessment and feedback, and other tools reminding providers to check immunization history, as well as strong consistent recommendation and promotion by providers for the HPV vaccine¹⁰. Increase in collaboration and efforts that address system-level barriers to vaccination will help increase overall HPV vaccine uptake⁷.

HPV initiatives in Pennsylvania

In Pennsylvania (PA) the coverage among males with ≥1 HPV vaccine dose was 55.9%, ≥2 48.2% and ≥3 doses was 38.3%. The coverage among females with ≥1 dose was 62.2%, ≥2 56.4 and ≥3 doses was 47.8%¹¹. HPV vaccine uptake remains low with low compliance to complete the vaccination series. Therefore, strategies to increase HPV uptake is vital in preventing HPV-related disease.

In an effort to increase HPV awareness and promote HPV vaccination, the PA Department of Health (DOH) created a powerful documentary called “Someone You Love-the HPV epidemic”. The video follows five young women with HPV and shows how HPV infection has affected their lives. The PA DOH has utilized healthcare organizations to use the video as a tool to increase HPV knowledge and HPV vaccination uptake. In 2016, the PA DOH had set up a program called PROTECT Against HPV: A collaboration for community and provider outreach under Crawford Health Improvement Coalition (CHIC) to utilize the video as a tool through a school-based campaign, a healthcare campaign and a community campaign¹².

HPV knowledge, perception, and vaccination rate among college students

Knowledge of HPV and HPV vaccine in college students is low. A study by Lambert¹³ evaluated knowledge in two groups of college students who were subjected to HPV focused education that consisted of pre- and post-intervention questionnaires three months apart. The results showed a statistically significant improvement of HPV knowledge post-interventions even after three months. Dillard and Spear¹⁴ assessed knowledge of HPV and perceived barriers to being vaccinated against HPV virus at Penn State University. Results showed that although awareness of HPV and HPV virus was high; only 65% had knowledge of HPV related facts. The lack of knowledge about HPV is a common barrier to HPV vaccine uptake¹⁵.

The perception of low risk for HPV and institutional barriers were cited as the most common reasons for parent’s refusal to vaccinate their children¹⁶. A literature review regarding attitudes and sexual behavior among women college students in the U.S. showed that although the women perceived HPV infection as a serious health risk and had a positive outlook on HPV vaccine; many do not perceive themselves at risk¹⁷. Effective unbiased education regarding HPV and HPV vaccine to increase knowledge with the emphasis of risk to the individual is an important aspect of HPV education. Strategies incorporating educational videos have proven to be an effective tool to increase knowledge¹⁸.

Study Method

To analyze the effectiveness of an educational video in increase knowledge, a quasi-experimental study, consisting of pre- and post-intervention test, followed by a brief question and answer session was developed. The Edinboro University Institutional Review Board approved the study protocol and a university conference room was set up for the project implementation.

Participants/Recruitment

There were 22 participants who completed the study. Participants were recruited from a university in northwest PA and surrounding communities. Recruitment methods included posted event fliers around the campus and community, and mass emails of the event sent to students and faculty at the university. Anyone interested in the event self-selected to participate. A cover letter was given to participants explaining the purpose of the study and assuring confidentiality and anonymity. It also explained that completion of questionnaires was implied consent to participate in the study. A separate survey from the DOH was given to participants, which were shared with the DOH for data collection.

Inclusion and Exclusion Criteria

Inclusion criteria included anyone age 18 yrs. old and older and able to speak, read and understand English. Exclusion criteria is anyone who under 18 years of age and is not able to speak, read and understand English.

Participants Demographic

There was a total of twenty-two participants. Seven were males and fifteen were females. Twenty-one were in between ages 18-26 years old. Seventeen of the participants were white/Caucasians, two were Hispanic/Latino, one Black/African American and two identified themselves as “other” in regard to race and ethnicity. Sixteen of the participants had some college credit, no degree as highest level of education achieved. Three selected diploma or the equivalent (GED), one with Bachelor’s degree and one with Doctorate degree.

Instrument

The instrument used for knowledge assessment consisted of eight questions that were self-authored based on the review of literature, and previously used tools in other research studies. The questions created were regarded by the author to be the best tool to assess the knowledge level where knowledge would be low.

Intervention

An eight-question survey was giving prior to the educational session which consisted of viewing “Someone You Love-the HVP epidemic”, followed by question and answer session from a panel of experts on HPV. Following the session, the same eight question test was given to participants. An additional survey questionnaire created by the PA DOH was taken by participants post-intervention.

Data Analysis

The pre- and post- test were compared for change in knowledge. Table 1. lists the scores of the pre- and post-tests. Table 2. lists the questions and the percentage of improvement post educational session per question. Figure 1. is the summary results of a paired t-test for the two datasets at 95% confidence interval. The histogram of differences between previewing scores and post viewing scores is also included. Figure 2. is the before and after Poisson capability comparison analysis summary.

The average test score increased from 77% pre-educational session to 93% post-educational session. The paired t-test indicate a significant statistical difference between the two results with p-value of < .005 and a t-value of -4.31 which represents the magnitude of variation in the test scores. The capability comparison test on the incorrect data to determine the effect viewing the educational video show the change of getting a perfect score on the post- test improved from 79.7% to 93.4%. When the incorrect answers are regarded as a defect among the 22 tests, showing the educational video reduced the incorrect answers by 70%.

Discussion

The study’s result showed an increase in knowledge among the participants post-educational intervention. This has implications on learning; that an educational video on HPV can be utilized to increase knowledge. A limitation to this study is the small sample size, thus it cannot be generalized. In addition, causality in this case can’t be suggested in a pre- and post-test design with a small sample size. However, the study reflects current literature that an educational video aids in increasing knowledge in participants. In addition, the instrument used is self-authored and did not undergo rigorous reliability and validity test. But in a study of this magnitude, this is not necessary. The questions however, were reviewed and approved by a content expert on HPV.

Conclusion

Seventy-nine million Americans are infected with HPV virus that can cause cancer. The use of media to enhance teaching and learning, and ultimately knowledge has been used for decades. An educational documentary can be a powerful learning experience by increasing student’s engagement and knowledge retention. It complements and diversifies traditional approaches to learning. Increasing knowledge of HPV and HPV vaccine can aid in decreasing the prevalence and incidence of HPV infection.

The study results showed a statistically significant increase in the participants knowledge after the focused educational intervention (p = <.005). Therefore, the use of an educational video such as “Someone you love-the HPV epidemic” along with a brief question and answer can be utilized as a powerful tool to increase knowledge. Further study is needed to assess generality by increasing the number of participants in varied settings. Future research is needed to assess whether increase knowledge of HPV and HPV vaccine leads to increase vaccination and compliance to series completion.

References

1. Centers for Disease Control and Prevention (CDC). CDC clinician FAQs: CDC recommendations for HPV vaccine 2-dose schedule, 2017. https://www.cdc.gov/hpv/hcp/2-dose/clinician-faq.html. Accessed on April 4, 2017.
2. Centers for Disease Control and Prevention (CDC). HPV for clinicians, 2017. https://www.cdc.gov/hpv/hcp/index.html. Accessed on March 24, 2017.
3. Centers for Disease Control and Prevention (CDC). HPV vaccine information for clinicians-Fact sheet, 2016. https://www.cdc.gov/hpv/hcp/need-to-know.pdf. Accessed March 27, 2017.
4. Coyne-Beasley T, Hochwalt BE. Protecting women against Human Papillomavirus benefits, barriers, and evidence-best strategies to increase vaccine uptake. North Carolina Medical Journal. 2016;77(6):402-405. doi: 10.18043/ncm.77.6.402.
5. Centers for Disease Control and Prevention (CDC). Many adolescents still not getting HPV vaccine, 2015. https://www.cdc.gov/media/releases/2015/p0730-hpv.html. Accessed from February 20, 2017.
6. Centers for Disease Control and Prevention (CDC). What is HPV. https://www.cdc.gov/hpv/parents/whatishpv.html. Accessed on March 24, 2017.
7. Holman DM, Roland KB. Barriers to human papillomavirus vaccination among U.S. adolescents: A systematic review of literature, 2014. Journal of the American Medical Association Pediatric. 2014; 158(1), 76-82. doi:10.1001/jamapediatrics.2013.2752.
8. Garcia J. A review of barrier to HPV vaccination among teen. Medscape. 2013. http://www.medscape.com/viewarticle/814968. Accessed March 18, 2017.
9. Burke SC, Vail-Smith K. Getting vaccinated against HPV: Attitudes, intentions and perceived barriers of female undergraduates. College Student Journal. 2010; 44(1): 55-63.
10. Centers for Disease Control and Prevention (CDC). The need for strategies to increase immunization levels, 2016. https://www.cdc.gov/vaccines/pubs/pinkbook/downloads/strat.pdf. Accessed March 1, 2017.
11. Centers for Disease Control and Prevention (CDC). National, Regional, State, and Selected Local Area Vaccination Coverage Among Adolescents Aged 13–17 Years — United States, 2015, 2016. MMWR Morb Mortal Wkly Rep. 2016; 65(33): 850-858.
12. Crawford County Health Improvement Coalition. http://crawfordcountypartnership.org/2016/04/12/protect-against-hpv-project-2016/. Accessed March 25, 2018.
13. Lambert EC. College students’ knowledge of human papillomavirus and effectiveness of a brief educational intervention. The Journal of the American Board of Family Practice. 2001;14(3):178-83. https://www.ncbi.nlm.nih.gov/pubmed/11355049. Accessed March 25, 2018.
14. Dillard JP, Spear ME. Knowledge of human papilloma virus and perceived barriers to vaccination in a sample of US female college students. The Journal of American College Health. 2010; 59(3):186-190. doi:10.1080/0744848.2010.493189.
15. Sheaves CG. Influence of education strategies on young women’s knowledge and attitudes about the HPV vaccine. National Association of Nurse Practitioners in Women’s Health. 2016;4(4). https://npwomenshealthcare.com/influence-education-strategies-young-womens-knowledge-attitudes-hpv-vaccine/. Accessed on June 25, 2017.
16. Navalpakam A, Dany M. Behavioral perceptions of Oakland University female college students towards human papilloma virus vaccinations. PLos One. 2016; 11(5):e0155955. doi:10.1371/journal.pone.0155955.
17. Ratanasiripong N. A Review of Human Papillomavirus (HPV) Infection and HPV Vaccine–Related Attitudes and Sexual Behaviors Among College-Aged Women in the United States. Journal of American College Health. 2012; 60(6): 461-470. doi:10.1080/07448481.2012.684365
18. Krawczyk A, Lau E. How to inform: Comparing written and video education interventions to increase Human Papillomavirus knowledge and vaccination intentions in young adults. Journal of American College Health. 2011;60(4): 316-322. doi: 10.1080/07448481.7011.615355.