HPV vaccination: knowledge, attitudes and beliefs in the Chinese population
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Introduction Cervical cancer is the fourth most common cancer in women worldwide. An estimated 62,000 cases of cervical cancer occur annually in China, accounting for 12% of global incidence. Virtually all cervical cancers are related to infection by Human Papilloma Virus (HPV): effective HPV vaccines have been developed and vaccination programmes introduced in many countries over the last decade. Given the burden of cervical cancer in China, it is imperative that effective primary and secondary prevention strategies are introduced. Effective introduction of HPV vaccination programmes will require education and information strategies that are informed by a comprehensive understanding of the knowledge, attitudes and beliefs about HPV infection and its relationship to cervical cancer in the Chinese population. Aims and objectives The aims of my thesis are: 1) to systematically review the evidence from the Chineselanguage literature in relation to knowledge of and attitude towards HPV infection and HPV vaccination, and 2) to explore knowledge and attitudes about HPV infection, HPV vaccination and cervical screening amongst teenagers in Heilongjiang province in China. Methods I undertook a systematic literature review using two electronic Chinese databases – the ‘Chinese National Knowledge Infrastructure’ (CNKI) database and the ‘Wanfang’ database. These were searched from inception through November 30th 2012: MeSH terms were applied to both Chinese databases. Manual searching of relevant online journals was also undertaken. Following selection of papers based on pre-determined inclusion and exclusion criteria, quality assessment was carried out using a modified quality assessment checklist, and included studies were classified as good, fair or poor quality. Due to heterogeneity of populations and survey instruments a narrative approach was adopted for data synthesis. I also undertook a questionnaire survey of high-school students in China. Questions were designed based on the Health Belief Model, informed by findings from my systematic review, and refined through cognitive interviews prior to field work in early 2014. The survey targeted students in five public high schools in one middle-income city (Mudanjiang city) and two small counties (Ning’an and Hailin) of Heilongjiang province; 3788 young people aged 14-22 years participated. Descriptive statistical analysis was used to summarise demographic characteristics; initially differences were identified using the chi-square test. Factor analysis was applied to identify attitude patterns and logistic regression analysis models were applied to determine the association between attitude (potential predictors) and acceptability, attitude and levels of knowledge. Results Forty seven articles met my inclusion criteria and were included in the systematic review. All included studies were published between 2006 and 2011; all were cross-sectional questionnaire surveys with sample sizes ranging from 100 – 9,865. The quality of included studies varied considerably. Included populations ranged from the general public, to young people, and health professionals. Awareness of HPV and knowledge of the relationship between HPV and cervical cancer, and of the sexually transmitted nature of HPV, were the main issues examined. Awareness of HPV was low among all non-health professionals groups. Similarly, understanding of the relationship between HPV infection and cervical cancer and of the sexually transmitted nature of HPV was low. However, significant differences in awareness and knowledge were found, based on urban/rural status, ethnicity and age. Uighur women had the lowest awareness and knowledge levels, followed by rural women adults, and teenagers. Acceptability of HPV vaccination varied in terms of the vaccine target recipients (whether adult women, or for their daughters), and between health professionals and the general public). Reported levels of HPV vaccine acceptability (for women adults themselves and for their daughters) were higher in North China compared to South China. Health professionals were less willing to accept the vaccine for their daughters than they were to receiving it themselves. The cost, source and appropriate age for HPV vaccination were also frequently examined issues. Importantly, a high proportion of the health professionals believed that the appropriate age for vaccine was over 18 years old for girls. 3788 participants aged 14-22 years were included in the questionnaire survey, with 54% females and 20% urban students. Overall awareness of HPV was 13.2% and acceptability of the HPV vaccine was 68%. Knowledge levels varied in different content areas; for example 74% of respondents knew that HPV vaccination is not 100% effective against cervical cancer while only 6% knew that poor personal hygiene did not increase the risk of contracting HPV infection. Attitudes towards HPV infection and vaccination were also interesting and novel; the greatest concern about HPV vaccination was minor side effects (72%). The highest-rated source of recommendations about HPV vaccination was parents (66%), while there were concerns expressed about ‘gossip’ in relation to HPV vaccination (51%). No urban/rural differences were found in knowledge and attitudes - gender differences existed, but depended on specific circumstances. Participants who were willing to accept HPV vaccination were more likely to be influenced by others, to report high perceived severity of HPV and cervical cancer, to perceive benefits of HPV vaccination and to score well on knowledge questions. Participants with high knowledge scores for HPV infection and vaccination were more likely to consider HPV infection and cervical cancer to be serious, and were less likely to associate HPV infection with stigma. Participants who had high levels of awareness of HPV infection were more likely to be influenced by others in relation to accepting HPV vaccination. Discussion My thesis has produced new and novel findings in relation to HPV vaccination knowledge, attitudes and beliefs in China. Low levels of awareness and knowledge amongst Chinese people may be influenced by traditional Chinese culture, which perhaps makes people more reluctant to consider issues related to sexual practices. Another possible explanation is that people tended to under-report knowledge of HPV when answering the questions in the survey in order to conform to social norms in China - these topics are highly sensitive in China. High levels of acceptability of HPV vaccines may have also been influenced by ‘ways of thinking’ among Chinese people; their natural inclination is to accept all recommendations for vaccination from government agencies – so they may not have thought hard about this choice. There is optimism in the Chinese population that cancer can be prevented by vaccination – indeed, they are inclined to believe it will prevent disease that can generate serious health impacts in the future. Nevertheless, some Chinese people have conservative attitudes towards the effectiveness of HPV vaccination and some suspicion of the drug companies which produce these vaccines. There were significant methodological issues in my comparisons of Western and Chinese literature. Western literature is more likely to comprise good quality studies – typically there are better-defined sampling frames, more valid and reliable instruments and robust theoretical frameworks. The difference in quality between Chinese and Western literature arises from the stricter rules for reporting and evaluation in western publications and the relatively low publishing standards in Chinese literature. My thesis also details a number of methodological issues which arose in conducting my questionnaire survey – ideally, I would like to follow up the work I have done with a multi-centre population-based study among teenagers in China (an idea which I will pursue once I return to China). This would hopefully provide better quality information on the influences of factors such as socio-economic status and family background in determining acceptability of HPV vaccination. Nevertheless, my relatively modest, school-based study has, I believe, produced results which add to the information available to health care planners and policy makers in the field of HPV vaccination in China. Conclusion My systematic review is, to my knowledge, the first to identify and synthesise findings about knowledge of and attitude towards HPV infection and vaccination in the Chinese literature – as such, it addresses a gap in currently available evidence. Although there are methodological limitations in Chinese literature (with more poor quality studies), the results still have implications for further health education intervention programmes and health policy. My questionnaire survey was also a ‘first’ in many ways – it explored attitudes towards HPV vaccines based on Health Belief Model among Chinese teenagers and examined HPV related stigma among mainland Chinese teenagers. Low levels of awareness and knowledge and conservative attitudes towards sexually related infections suggest the impact of Chinese traditional culture and a range of other social and financial constraints in China. Hence, there is a great deal to be done before HPV vaccination can be implemented in China – there are educational needs, and in many areas societal and cultural attitudes need to be challenged. Significant changes are also need in government policy and investment – these are major challenges for health care in China, and I sincerely hope my thesis will contribute to these important debates.