Effect of an educational intervention on HPV knowledge and vaccine attitudes among urban employed women and female undergraduate students in China: a cross-sectional study

Despite recent strides made in HPV vaccination and education, over half a million women worldwide develop cervical cancer each year. Over 85% of these cases occur in developing countries such as China due to the lack of effective screening and prevention programs [1, 2]. The incidence of cervical cancer in Mainland China increased from 5.14 persons per 100,000 in 2004 to 6.87 persons per 100,000 in 2008 [3–5]. Persistent infection with high-risk human papillomavirus (hrHPV) subtypes has been established as the primary cause of squamous cell cervical cancer [6]. In China, HPV 16 and 18 are implicated in the etiology of over 84.5% of cervical malignancies [7, 8].

Both the bivalent and quadrivalent HPV vaccines have been demonstrated to effectively prevent the development of high-grade cervical neoplasias, particularly when given to girls before they become sexually active [9–12]. The prophylactic HPV vaccines currently undergoing clinical trials in Mainland China hold potential to significantly decrease cervical cancer mortality rates in the future. Prior to the licensure and widespread use of these vaccines, HPV education plays a crucial role in vaccine acceptability in the general population [13]. Studies have demonstrated that mothers with higher HPV knowledge have increased vaccine uptake and express greater willingness to vaccinate their children [14, 15].

Previous studies on knowledge and attitudes about HPV among different groups of Chinese women have revealed high vaccine acceptability but low levels of knowledge about HPV and cervical cancer [16]. A pilot study by Kwan et al. (2008) demonstrated only 38% of women in Hong Kong had heard of HPV [17]. Zhao et al. (2012) confirmed that knowledge about HPV was similarly low in Mainland China, with 34% of urban women, 16% of rural women, and 44% of government officials having heard of HPV. Of concern, less than 20% of healthcare workers correctly identified the ideal time for HPV vaccination as prior to sexual debut [18]. These data suggest a strong need for HPV and HPV vaccine education in the general female population in Mainland China.

In recent years, there has been a proliferation of HPV education studies internationally. Educational instruction on HPV-related diseases has been demonstrated to effectively raise HPV knowledge and vaccine acceptability in America [19, 20], Sweden [21], Korea [22], and Turkey [23, 24]. Although previous studies have assessed the effect of education instruction on HPV-related knowledge in Hong Kong [25–27], the differing socioeconomic factors and the availability of the HPV vaccine in Hong Kong make the findings less applicable to Mainland China. In our present study, we report the results of a multi-center study examining the effect of a brief educational intervention on HPV vaccine-related knowledge and attitudes among employed women and undergraduate female students in Mainland China.

From August to November of 2011,1146 employed women and 557 female undergraduate students were surveyed. After excluding incomplete questionnaires, 1061 and 325 surveys were included in the post-interventional analysis, respectively.

Pre-intervention HPV- related knowledge

At baseline, 1089/1146 (95%) of employed women and 440/557 (79%) of female undergraduate students had heard of cervical cancer. However, HPV knowledge was low in both groups, with only 321/1146 (28%) of employed women and 66/557 (12%) female students having heard of HPV. 237/1146 (21%) of employed women and 40/557 (7.2%) of students knew that HPV infection causes cervical cancer, but only 51/1146 (4.5%) and 18/557 (3.2%) knew the association between HPV and genital warts, respectively. Similarly, only 147/1146 (13%) employed women and 62/557 (11%) students had heard of the HPV vaccine. 212/1146 (18%) and 69/557 (12%) knew that the vaccine could prevent cervical cancer, respectively. 103/1146 (9%) of employed women were not concerned about developing cervical cancer. Knowledge of HPV and cervical cancer did not differ significantly between women from different geographical regions (p > 0.05). Baseline HPV knowledge is summarized in Figure 2.

Post-interventional HPV-related knowledge

After a brief educational narrative about HPV and cervical cancer, HPV-related knowledge increased significantly. Comparison of pre- and post-interventional HPV knowledge is shown in Figure 3. Post-intervention, 947/1061 (89%) of employed women knew that HPV infection caused cervical cancer from 237/1146 (21%) at baseline, a 4.2 fold increase from baseline (χ ²  = 1041.8, p < 0.001). Among undergraduate students, knowledge of this causal relationship increased over seven-fold from 40/557 (7.2%) to 193/325 (59%), (χ ²  = 278.5, p < 0.001).

Post-interventional knowledge about HPV-related diseases and risk factors for HPV infection also increased significantly. In particular, correct identification of the ideal time for HPV vaccination as prior to sexual debut increased significantly from 246/1146 (21%) to 725/1061 (68%) in employed women and 205/557 (37%) to 223/325 (69%), (χ ²  = 79.6, p < 0.001) in female students. Employed women also reported increased intention to undergo routine gynecologic exam after the intervention from 601/1146 (52%) to 974/1061 (92%), (p < 0.001).

The brief educational intervention in our study effectively raised HPV and HPV vaccine knowledge in undergraduate students and employed women, and also increased vaccine acceptability. Post-intervention, women were twice as likely to report willingness to vaccinate their children and correctly identified younger ages as ideal for receiving the HPV vaccine. This is of particular significance because a recent study suggests for optimal vaccine compliance, girls in China should be vaccinated between the ages of 13-15, prior to concluding their mandatory schooling and becoming sexually active [18].

While the HPV vaccine may reduce the incidence of cervical cancer in the future, clinical trials across China are ongoing. An effective HPV education program that addresses specific knowledge gaps and common questions among women of different regions, education levels, and cultures has been demonstrated to increase the success of large-scale vaccination programs [21]. Studies in the U.S. have found that educational programs should emphasize vaccine effectiveness and the high likelihood of HPV infection, and address barriers to vaccination [14]. A similar study in Japan found that vaccine safety and cost should be addressed to increase maternal vaccine acceptability for their children [28]. Women also reported increased vaccine acceptability for themselves and their children after hearing physician and government endorsements of the HPV vaccine [25, 28].

To our knowledge, the present study represents the first evaluation of a large-scale HPV educational intervention in Mainland China. Kwan et al. [26, 27] have conducted similar HPV knowledge and education studies in Hong Kong, yet no similar educational interventions have been conducted in Mainland China. A previous study by Zhang and colleagues [18] examined HPV knowledge alone in China among the general female population, healthcare personnel, and government officials. Our results confirm their findings of low baseline HPV knowledge among employed women and female undergraduate students. In addition, our survey of employed women and female undergraduate students paints a more comprehensive picture of HPV knowledge in different female population groups across Mainland China.

The results of our present study indicate that baseline HPV knowledge is low among employed women and female undergraduate students in northern, eastern, central, southern, and southwestern regions of China. Through our study, we also gained valuable insight into the preferred methods of obtaining HPV-related information and social beliefs held among Chinese women. Employed women and female college students preferred to receive HPV-related information via school or hospital-based lectures. They also believed that a national organization such as the Center for Disease Control should be responsible for providing the vaccine. In addition, vaccine safety, efficacy, and cost remained concerns and barriers to vaccination. Women had no preference for either the domestic or foreign HPV vaccine, but believed that the government should support and partially subsidize the cost. Future HPV education programs can focus on addressing these aforementioned issues. Furthermore, over 76% of employed females believe that getting vaccinated is a societal responsibility that should be shared by both genders. Thus, a government-sponsored, school-based education program can effectively disperse safe intercourse practices and HPV vaccine information to both male and female students.

Strengths of our study include the relatively large population sampled across five main geographical regions of Mainland China. We also targeted employed women and undergraduate female students, two populations who have not been surveyed before. Our findings are consistent with previous studies, which found that HPV knowledge and vaccine acceptability were higher among college-educated women [18, 25].

Limitations of our study include the cross-sectional design. While our educational intervention significantly increased post-test HPV knowledge and vaccine acceptance, the strength of causality is limited by the absence of a control group. Also, although our questionnaire was adapted from previous studies, we did not apply a scale to assess its validity. Future large-scale studies should devise a reliability scale to evaluate the questionnaire. Furthermore, our study was mainly carried out in urban centers among women with higher education levels thus due to the potential sampling bias, our findings may not be generalized to the entire Chinese population. HPV knowledge and vaccine receptivity have been shown to vary widely based on region, sociodemographic factors and education level [14, 16]. In 2007, a survey of 400 Uyghur women in Xinjiang found only 5% had heard of cervical cancer [29]. A more recent study in 2011 on 1005 Han, Uyghur, and Muslim women residing in Xinjiang found that only 5.2% of Uyghur women and 11.5% of Muslim women knew the association between HPV infection and cervical cancer, suggesting that the findings of our study may not be generalized to different groups of Chinese women [30]. This highlights the need for culturally salient HPV and cervical cancer education especially among Chinese ethnic minority populations. Furthermore, while HPV and HPV vaccine knowledge significantly improved immediately following the brief educational intervention, its lasting impact is unknown. It is also uncertain whether vaccine acceptability and positive attitudes towards vaccination would persist and translate into higher vaccination rates.

Our study demonstrates that incorporation of our educational initiative into a government sponsored or school based program may improve willingness to accept HPV vaccination. The potential implications of our study are far-reaching during this pivotal time of HPV vaccine clinical trials in China. It is important to establish the link between HPV infection and the development of cervical cancer, and to educate women on the ideal time to vaccinate their children. Studies have shown that maternal attitudes towards vaccination greatly impacts vaccination rates among children. It is also imperative to dispel common beliefs that only women with multiple sexual partners need to be vaccinated.

Future directions for research include the development of a longitudinal, national HPV education program appropriate for school-based curriculum. Due to our limited participant sampling, our findings may not be generalized to the entire heterogeneous Chinese female population. Widespread implementation among different geographic regions and minority populations across China would shed light on the long-lasting impact of HPV education. Also, it is important develop evaluation and feedback tools to assess the effectiveness of the program. Lastly, follow-up studies must be performed to see if increased HPV and HPV vaccine knowledge translates into higher vaccination rates and vaccine compliance within China.