Study design

A questionnaire survey was administered to first year medical students at a UK university (University of Glasgow). Medical students were chosen as a "best case scenario" of HPV knowledge acquisition among young adults because they are an educated population and may have a greater awareness of current medical issues: entry into medical school at Glasgow is by interview where prospective students are questioned on knowledge of current topics in human health. Moreover, as health professionals of the future, they may have high motivation to pay attention to and acquire current PHI. Student knowledge and opinion was assessed in 2008 in that year’s intake of medical students i.e. immediately following the implementation of HPV vaccine delivery in the UK, and then one year later in the 2009 intake of students. The same questionnaire was administered in both years.

Survey questionnaire

An 8-item closed-ended questionnaire, with, for females, a 3-item data gathering section to determine stage of vaccination, intention to attend smear testing and smear testing status, was developed from a literature review and in consultation with a vaccine specialist at Health Protection Scotland and NHS public health information specialists. No studies examining detailed knowledge of HPV in the UK were reported in the literature at the time of this study so three questions relating to HPV were designed to address specific points regarding HPV knowledge discussed in leaflets delivered to vaccinees and in other PHI. The draft questionnaire was piloted on students in the final year honours virology classes of both years. The questionnaire was then reviewed by members with relevant expertise of the University of Glasgow Ethics Committee and modified according to feedback received. The survey was administered at the same time of year, in November, first in 2008 and then in 2009. This timing was chosen because it preceded taught modules on cancer, including cervical cancer. The questionnaire was completed in a ten minute period at the end of a teaching session in a lecture theatre. One of the researchers introduced the study and explained the ethical permissions and voluntary nature of participation. Students made aware of how anonymity would be ensured. Although signed informed consent was given, the consent forms were collected separately to the questionnaires so that no questionnaire answers could be traced back to an individual. Ethical approval was obtained from the University of Glasgow’s Faculty of Biomedical and Life Sciences Ethics Committee.

In 2008 the timing of the survey was chosen to be immediately following first roll out of the vaccine (September 2008) after a summer's intensive public health campaign. This included television, radio, internet, media, cinema and billboard adverts and age-directed leaflets available in public places, community and health centres and GP surgeries. Few females in the population were vaccinated in 2008. In contrast, in 2009, many of the female students had been offered the vaccine, delivered in association with appropriate PHI. Moreover, there was a sustained high level PHI campaign throughout 2009. In particular, during this period there was extensive media coverage of the illness and death due to cervical cancer of the celebrity Jade Goody [21, 22].

The study group

Data collation and analysis

Data were input into Microsoft Excel 11.5. Exact binomial, Randomisation and Chi-Squared tests were used to compare between group data. Differences were considered significant if p< 0.05. Analyses focused on questions pertaining to knowledge of HPV and the HPV vaccine.

Knowledge of details of HPV and its association with cervical cancer

Assessing potential impact of the vaccine on uptake of cervical smear testing

In 2008, 94% and in 2009, 87.3% of the students assessed the cervical screening programme as “very important”. In Scotland, women are invited for their first smear test at age 20. Some of the female students in the survey populations had already attended for testing: in 2008, 16.0% (n=16) of students (97% of those eligible for screening (i.e. ≥20 years of age)) had been for a smear test while in 2009, 13.3% (n=15) (68% of those eligible for screening) had been tested. In both years the majority of women answered positively when asked if they would go for a smear test when invited. Importantly, in 2009, 94% of females who had been fully vaccinated said they would attend for a smear test when invited.

Exposure to public health information on the HPV vaccine

Summary

Many studies in different countries in a range of socio-economic groups have demonstrated an overall lack of awareness of HPV and its link with cervical cancer [9–11, 16, 24, 25]. This study represents one of the first reports of the knowledge of educated young people in the UK of details about HPV infection, the HPV vaccine and cervical cancer, and importantly, how knowledge changed within the first year of introduction of the vaccination programme. The surveys were carefully timed to question the students when they would have been maximally exposed to PHI and media information on HPV and the HPV vaccine. Moreover, the students may have had more motivation to pay attention to details in the PHI than most other young people of this age group because their successful entry to medical school could depend on their displaying clear knowledge and understanding of facts on HPV at interview. There are few studies comparing detailed knowledge of HPV in males and females. The young male population could have a role in encouraging their female peers to be vaccinated so both genders were questioned in each year’s cohort. The study included unvaccinated women and women who were in the age group between being offered the vaccine and being called for cervical screening. The vast majority (99%) of the students, male and female, questioned in each year indicated that they had seen or heard information on the HPV vaccine indicating some efficacy of PHI. The questionnaire assumed that the students would have some knowledge of HPV and cervical cancer and indeed it was clear that the level of knowledge of this educated population was probably greater than that of the general population [10] as recently suggested [26].

Knowledge about specific details of HPV infection

The UK PHI leaflets accompanying HPV vaccination note the sexually transmitted nature of HPV. Surprisingly, although most students seemed to appreciate this fact, in agreement with another study [27], the 2009 survey showed a small decrease in the percentage of students who understood that HPV was sexually transmitted. This was despite a significant step-up in the PHI campaign surrounding HPV and its link with cervical cancer from the summer of 2008 through to autumn 2009 and the media coverage early in 2009 of the death from cervical cancer of the young celebrity Jade Goody [21, 22]. However, the level of knowledge of the sexually-transmitted nature of HPV in our cohorts was much higher than that in another study of a similar age group of school students in Germany where less than 50% understood that HPV was a sexually transmitted infection [28]. It is becoming increasingly clear from similar surveys in a number of countries that even among educated young people there is a lack of understanding of the sexually transmitted nature of HPV infection [18, 19, 29–31].

PHI leaflets clearly state that the vaccine protects against 70% of cases of cervical cancer. However, it is not made clear that the remaining 30% of cases are caused by other HR-HPV types. Consequently, anecdotal evidence suggests that the public may believe it is possible to develop cervical cancer without being infected with HPV [16, 32, 33]. Students were asked to guess what percentage of cervical cancers was caused by HPV. Only around half of men and women in 2008 understood that HPV caused between 80 and 100% of cervical cancers. There was a decrease in understanding this fact between the 2008 and 2009 surveys and a greater percentage of men responded incorrectly in 2009.

Relationship between vaccination and HPV knowledge

The vaccine PHI intended to inform the public that the vaccine protected against two types of HPV. However, in 2008 around half the survey population did not appear to appreciate this fact. Male understanding did not increase by 2009 but females gave a larger number of correct responses in that year. This could be due to the increased percentage of vaccinated female students in 2009 that correlated with an increased number who claimed to have seen or heard HPV information in formal education, as expected due to the PHI delivered to vaccinees. However, as noted above, a lower percentage of the 2009 cohort of women realised that HPV caused most cervical cancers. Therefore our evidence is equivocal that PHI delivered with the vaccine improved HPV knowledge.

Acquiring knowledge: gender differences in HPV knowledge

Although there was some evidence of gender differences in HPV knowledge, especially in the 2009 cohort, gender did not have a significant difference on the sources of information on HPV. However, a much higher percentage of male students reported receiving information from word of mouth and more males in 2009 compared to 2008 were unable to rate PHI on the HPV vaccine. Interestingly, although the males in the study displayed knowledge of HPV association with cervical cancer, the majority answered ‘no’ to a question included in the survey “Do you think males should be offered the vaccine?” This could indicate perception of HPV vaccination as a female issue.

Limitations of the study

The study has some limitations. Prior to administering the questionnaire it is possible that some students had begun to prepare for the oncology portion of their course by reading recommended materials and had thus acquired a greater appreciation of the subject prior to questioning. Some homogenisation of answers could have occurred through students comparing answers in class. The restricted time period (ten minutes) for filling in the questionnaire was designed to avoid this. In itself this may have introduced another limitation because the short time period may have led the students to provide rapid, poorly considered responses.

Ethical approval

University of Glasgow Faculty of Biomedical Sciences Ethics Committee project approval number FBLS 0825 17/11/2008 and FBLS 0930 01/10/2009.