Date Published: November 18, 2016
Publisher: Public Library of Science
Author(s): Shazia Rashid, Satyanarayana Labani, Bhudev C. Das, Kalimuthusamy Natarajaseenivasan.
Infection of specific high risk Human papillomaviruses (HPVs) is known to cause cervical cancer and two prophylactic vaccines have been developed against two major high risk HPV types 16 and 18 for prevention of cervical cancer. Because of societal, religious and ethical issues associated with the vaccination of adolescent girls in India together with lack of awareness about HPV and HPV vaccines, no successful HPV immunization program has been employed in India.
To determine knowledge, awareness and attitude of college students on HPV, HPV vaccine and cervical cancer.
A questionnaire-based survey was conducted in a total of 1580 undergraduate students between the age group 16–26 years comprising 684 girls and 876 boys.
Out of a total of 1580 students, girls had more knowledge about cervical cancer (82.45%, p<0.001), HPV (45.61%, p<0.001) and HPV vaccines (44%, p<0.001) when compared to those in boys. However, knowledge about the types of HPV and vaccines was poor. Interestingly, students from biology-major had more knowledge and awareness about cervical cancer (81.89%, p<0.001) and HPV (46.58%, <0.001) when compared to non-biology students. Girls from both biology and non-biology group had higher awareness compared to boys. Analysis of odds ratio (ORs) along with 95% CI showed older girls with 1.2 to 3 fold (p<0.05) higher knowledge than boys. All students agreed that girls should get vaccinated against HPV (p<0.001). It is suggested that there is a need for educational intervention and awareness campaigns to augment HPV immunization program for control of cervical cancer in India.
Cervical cancer is the third most commonly diagnosed cancer worldwide and the fourth leading cause of cancer death in women  but in India, it is the leading cancer among women  accounting for more than 74,000 deaths per year .
Data collected through questionnaire were tabulated and analysed using various statistical methods. Out of a total of 1580 students interviewed, the number of girls was 684 and 876 boys who were again categorised based on their age into younger (≤ 19years) and older (> 19years) and background in biology or physical sciences. Of the total students, girls had more knowledge about cervical cancer (82.45%, p<0.0001), causes of cervical cancer (11.54%, p<0.001) and HPV being the major cause of cervical cancer (45.61%, p<0.001) and also about genital warts (42.54%, p<0.001) compared to boys (Table 2). Among girls, older girls were more aware compared to younger girls about cervical cancer (88.55%, p<0.0001) and HPV as its major causative agent (57.23%, p<0.0001)(Table 2).There was no significant difference in awareness about oncogenic HPV types between girls and boys in general although a small percentage of older girls were more aware (2.02%, p<0.0001) than the younger girls about the oncogenic HPV types. Among boys, older boys had more knowledge about the cervical cancer (64.45, p<0.001), HPV as the major cause of cervical cancer (33.52%, p<0.001) and also responsible for genital warts (38.15, p<0.001)(Table 2). It was also observed that girls were more aware about the existence of HPV vaccines (44%, p<0.001) and eligibility of vaccination (6.28%, p<0.001) compared to boys. However, knowledge about the names of the vaccines was low in both girls and boys. Among girls, older girls were more aware about the existence of HPV vaccines (52.52%, p<0.001). In response to a question regarding mandatory HPV vaccination for girls, significant number of girls responded positively compared to boys (73.24%, p<0.001). A good percentage of older boys also responded positively and were in favour of girls getting vaccinated against HPV (63.58%, p<0.05)(Table 2). Cancer of the uterine cervix is a major cancer in India in women but it is a curable cancer, if detected early. The two major high risk oncogenic HPV genotypes, HPV16 and HPV 18 most commonly associated with the development of cervical cancer, are highly prevalent in India [4–7]. Integrating knowledge and awareness programs with educational intervention for cervical cancer or HPV screening along with HPV vaccination will go a long way in reducing HPV infection and controlling cervical cancer in Indian women. The present study was carried out in undergraduate science and engineering students in an affluent private university set up with the main aim of getting information regarding the level of awareness and knowledge about cervical cancer, HPV and attitude towards HPV vaccination that may help in designing effective HPV screening and successful vaccination programs for the control of cervical cancer. We observed a close association between increasing age and higher HPV awareness especially among the girls. In general, girls who have passed through their teenage and from biology-background were more knowledgeable than others about cervical cancer, its causes and HPV being the major causative agent for cervical cancer (Tables 2 & 3). However, none of the students were aware about the cancer causing HPV types and names of the HPV vaccines which reflect that they have a very limited knowledge and understanding of the disease. It was also observed that although students of this University belonged to well-educated and affluent class families, the percentage of girls who got vaccinated was very low (7%). This is alarming because even after almost a decade of introduction of HPV vaccines, which are available in India since 2008, not many parents are interested to get their daughters vaccinated. It appears that several factors involving societal, religious and prejudice ideas, socioeconomic status including lack of knowledge, awareness and attitude might be the reasons for such a low coverage of HPV vaccination in India. Several studies have been conducted to analyse the awareness about cervical cancer and HPV among young women, both in rural and urban areas of India [13–17] and in other countries [18–20]. All these studies report that awareness and knowledge about cervical cancer is very poor among both young undergraduate and postgraduate students, from rural and urban areas which may be due to lack of education and exposure to print/ audio-visual media, including variety ofsocietal factors, social stigma and ignorance [21–23]. However, a study carried out earlier in undergraduate medical students in India show that they are well aware about the cervical cancer and its link to HPV infection . In general, girls have shown more awareness compared to boys (Table 2) and the same has also been reported recently by Hussain et al.. The level of awareness among students showed a strong association with the educational background in biology than in non-biology. Biology students were more aware about cervical cancer, HPV and HPV vaccination compared to non-biology students (Table 3). The study highlights the need to improve public health education in view of the lack of awareness about cervical cancer and its possible prevention by vaccination in the community . Studies have shown that imparting education has positive effect in encouraging and motivating men and women to participate in screening and vaccination programs. It has been reported recently that a brief educational intervention could increase college students’ performance on an HPV knowledge assessment from 45% to 79% 3 months later . Not only can this lead to early diagnosis of the disease but also successful implementation of HPV immunization programs for control of cervical cancer. The study suggests that the overall awareness and knowledge about cervical cancer, HPV and HPV vaccination are poor among college students and are strongly associated with the age and educational background of the students in biology. There is an urgent need for educational intervention—both formal and informal, not only for girls and boys from both biology and non-biology background but also for parents to change their attitude towards HPV vaccination. To achieve this, both print and audio-visual media may play a pivotal role. It is suggested that there is a need for incorporation of HPV vaccination in the National Immunization Program which can be integrated with the screening (VIA/ Pap/ HPV DNA) and national cancer control program, and eliminate the limitations of vaccine cost and poor awareness for successful control of HPV- induced cervical and other cancers. Source: http://doi.org/10.1371/journal.pone.0166713