Study Examines Healthcare Professionals’ Knowledge and Attitudes Toward HPV Vaccination
Introduction
Human papillomavirus (HPV) is one of the most common sexually transmitted infections worldwide, affecting up to three-quarters of sexually active individuals at some point during their lifetime. In 2006, an estimated 630 million people around the world were infected with HPV [1].
More than 200 HPV types have been identified, approximately 40 of which infect the genital mucosa. These types are classified according to their oncogenic potential. There is now overwhelming evidence that high-risk HPV types are the primary cause of cervical cancer and also contribute to cancers of other anogenital sites, including the anus, vagina, vulva, and penis. Low-risk HPV types are responsible for most cases of cutaneous and genital warts, recurrent respiratory papillomatosis, and other benign lesions [1–3].
Most individuals infected with HPV remain asymptomatic and may unknowingly transmit the virus to others. It is also possible to be infected with multiple HPV types simultaneously [4].
According to the World Health Organization (WHO), HPV vaccination significantly reduces the incidence of HPV-related disease and mortality. Several vaccines have been developed, including bivalent vaccines (targeting HPV types 16 and 18), quadrivalent vaccines (types 6, 11, 16, and 18), and nonavalent vaccines (types 6, 11, 16, 18, 31, 33, 45, 52, and 58). To achieve maximum effectiveness, vaccination should be administered before the onset of sexual activity, including vaginal, anal, or oral intercourse [6,7].
The Centers for Disease Control and Prevention (CDC), the Advisory Committee on Immunization Practices (ACIP), and the WHO recommend routine vaccination for girls between the ages of 9 and 13. Individuals who were not vaccinated earlier should receive catch-up vaccination through age 26 [7–9].
Primary healthcare professionals, particularly pediatricians and family physicians who routinely care for children aged 9–13 years, play a critical role in raising public awareness about the goals of the National Immunoprophylaxis Program (NIP). In Lithuania, HPV vaccination under the NIP was scheduled to begin on September 1, 2016 [10].
Vaccine hesitancy remains a challenge in Lithuania, making it especially important for healthcare professionals, parents, and patients to understand the risks associated with HPV infection, its potential consequences, and available prevention strategies. Adolescents and their parents should be informed that vaccination provides the most effective protection against HPV infection. Young people should also be encouraged to delay the initiation of sexual activity and, if sexually active, to maintain mutually monogamous relationships, avoid smoking, limit alcohol consumption, and adopt healthier lifestyle habits.
By educating patients and their families about HPV infection and the benefits of vaccination, healthcare professionals can help improve public understanding, strengthen trust in immunization programs, and increase vaccination uptake. Given the public health importance of this issue, we conducted a study to assess healthcare professionals’ knowledge of HPV infection and their attitudes toward HPV vaccination.
Study
A survey was conducted during scientific conferences for physicians held in Vilnius between September and December 2015. The study included family physicians, pediatricians, and nurses, for a total of 141 participants (Table 1).
An original questionnaire was developed based on previously published surveys and the latest scientific evidence regarding HPV infection. The questionnaire was designed to assess participants’ knowledge of HPV infection, their understanding of HPV vaccines, and their attitudes toward vaccination [1,2,4,9].
| Characteristics | Family Physicians (n=56) | Pediatricians (n=49) | Nurses (n=36) | p-value |
|---|---|---|---|---|
| Mean age (years) | 48.07 ± 14.05 | 46.57 ± 12.56 | 48.06 ± 9.16 | 0.795 |
| Min–max age (years) | 25–75 | 25–67 | 23–64 | |
| Sex, n (%) | 0.040 | |||
| Female | 43 (78.2) | 42 (85.7) | 35 (97.2) | |
| Male | 12 (21.8) | 7 (14.3) | 1 (2.8) | |
| Years of professional experience | 22.29 ± 14.7 | 20.51 ± 12.77 | 25 ± 11.45 | 0.308 |
| Workplace, n (%) | 0.014 | |||
| University hospital | 11 (19.6) | 18 (36.7) | 13 (36.1) | |
| Republican hospital | 3 (5.4) | 8 (16.3) | 9 (25.0) | |
| Regional hospital | 4 (7.1) | 3 (6.1) | 1 (2.8) | |
| District hospital | 5 (8.9) | 3 (6.1) | 4 (11.1) | |
| Outpatient clinic | 12 (21.4) | 10 (20.4) | 6 (16.7) | |
| Private clinic | 21 (37.5) | 7 (14.3) | 3 (8.3) |
One notable finding was that a considerable proportion of respondents incorrectly believed that HPV can be transmitted through blood. Nearly all participants recognized HPV as a cause of cervical cancer; however, only 45% were aware that HPV can also cause skin and external genital warts. Detailed findings regarding HPV transmission routes and HPV-associated diseases are presented in Table 2.
| Variables | Family Physicians (%) | Pediatricians (%) | Nurses (%) | p-value |
|---|---|---|---|---|
| HPV can be transmitted through: | ||||
| Kissing | 12.5 | 14.3 | 22.2 | 0.433 |
| Blood* | 23.2 | 14.3 | 33.3 | 0.116 |
| Poor hygiene* | 8.9 | 6.1 | 11.1 | 0.642 |
| Sexual intercourse | 92.9 | 98.0 | 100.0 | 0.258 |
| Heredity* | 0 | 0 | 5.4 | 0.064 |
| Contact between damaged skin or mucous membranes | 33.9 | 28.6 | 30.6 | 0.836 |
| Contact with an infected person's genitals | 58.9 | 46.9 | 50.0 | 0.444 |
| Mother-to-child transmission during vaginal delivery | 41.1 | 34.7 | 38.9 | 0.796 |
| Diseases caused by HPV: | ||||
| Cervical cancer | 100.0 | 100.0 | 97.1 | 0.242 |
| Vaginal cancer | 33.9 | 24.5 | 47.1 | 0.102 |
| Tongue cancer | 17.9 | 16.3 | 14.7 | 0.926 |
| Breast cancer* | 5.4 | 2.0 | 8.8 | 0.363 |
| Laryngeal papillomatosis | 32.1 | 20.4 | 20.6 | 0.299 |
| Skin and external genital warts | 55.4 | 42.9 | 39.2 | 0.228 |
| Penile cancer | 32.1 | 16.3 | 23.5 | 0.169 |
| Anal cancer | 25.0 | 14.3 | 14.7 | 0.294 |
| Tonsillar cancer | 10.7 | 6.1 | 11.8 | 0.619 |
| Measures that help reduce the risk of HPV infection: | ||||
| Frequent hand/foot washing | 3.6 | 0 | 11.1 | 0.032 |
| Delaying sexual initiation | 41.1 | 30.6 | 22.2 | 0.159 |
| Circumcision | 8.9 | 10.2 | 0 | 0.153 |
| Condom use | 80.4 | 65.3 | 77.8 | 0.103 |
| Vaccination | 89.3 | 93.9 | 86.1 | 0.481 |
| Having a steady sexual partner | 85.7 | 73.5 | 72.2 | 0.199 |
| Reducing/changing sexual partners less frequently | 8.9 | 4.1 | 0 | 0.148 |
| Treatment of other sexually transmitted infections | 21.4 | 4.1 | 13.9 | 0.034 |
| Cannot be reduced* | 0 | 0 | 2.8 | 0.230 |
Most respondents identified vaccination, maintaining a steady sexual partner, and condom use as measures that reduce the risk of HPV infection (Table 2). Further analysis revealed that younger healthcare professionals (p=0.017) and those with fewer years of clinical experience (p=0.009) provided more accurate responses regarding HPV prevention. Older participants were more likely to select only two or three correct responses from the eight options provided.
Assessment of knowledge about HPV vaccination showed that 80% of respondents believed girls aged 9–12 years should be vaccinated, 44.7% believed vaccination should be offered to women up to 26 years of age, 13.5% supported vaccination of boys aged 9–12 years, and 8.5% supported vaccination of men up to age 26.
Approximately three-quarters of respondents correctly indicated that girls aged 9–13 years require only two doses of the HPV vaccine. Younger physicians were significantly more likely to answer this question correctly (p=0.033).
However, one-quarter of participants incorrectly believed that HPV vaccines protect against all HPV types. Older and more experienced healthcare professionals were significantly more likely to provide incorrect responses (p=0.02).
Participants were also asked to identify high-risk HPV types. One-third incorrectly classified HPV types 6 and 11 as high-risk. Correct identification of the high-risk HPV types 16, 18, and 45 was achieved by 47% of physicians and only 22% of nurses (p=0.001).
A large majority of respondents (86.2%) correctly identified Cervarix as an HPV vaccine available in Lithuania, whereas only 64.2% mentioned Gardasil.
The survey also explored healthcare professionals’ attitudes toward HPV vaccination. Nearly all respondents (96.3%) agreed that HPV vaccination is necessary. However, although 88.9% stated that they would recommend vaccination to their patients, only 28.9% had vaccinated or planned to vaccinate their own daughter or niece.
Notably, 20.5% of participants believed that recommending HPV vaccination could increase the likelihood of earlier sexual activity among adolescents.
Respondents were also asked about HPV vaccination rates in Lithuania. The correct estimate of approximately 300–400 vaccinated girls and women annually was selected by only 15.9% of participants. Most respondents believed that fewer than 100 individuals were vaccinated each year.
According to the participants, HPV vaccination coverage could be improved through several measures, including:
- Providing the vaccine free of charge (98.5%);
- Educating parents and children in schools (82.2%);
- Strong and clear recommendations from physicians (70.4%);
- More frequent discussions about HPV vaccination during medical appointments (60%);
- Television advertising campaigns (54.1%).
Research Conclusions
The study findings demonstrate that healthcare professionals overwhelmingly support HPV vaccination and would generally recommend it to their patients. However, older and more experienced family physicians, pediatricians, and nurses displayed significantly lower levels of knowledge regarding HPV infection and its prevention.
These findings suggest that healthcare professionals should be encouraged to continually update their knowledge about HPV infection and vaccination, particularly as new vaccines and prevention strategies become available. Strong, evidence-based recommendations from healthcare providers remain essential for the successful implementation of the National Immunoprophylaxis Program.
The success of HPV vaccination depends on:
- The willingness of girls and women to be vaccinated;
- Parents’ willingness to vaccinate their children;
- Healthcare professionals’ willingness to actively recommend HPV vaccination.
Viktorija Žitkutė
Faculty of Medicine, Vilnius University
Assoc. Prof. Žana Bumbulienė
Clinic of Obstetrics and Gynecology, Faculty of Medicine, Vilnius University Hospital Santariškės Clinics
Supplement to the journal INTERNIST – Gynecology Highlights, 2016, No. 1
