Human Papillomavirus and Cervical ...

Human Papillomavirus and Cervical Cancer Knowledge health beliefs and preventive practicies, profilaktyka raka ...

s [ Pobierz całość w formacie PDF ]
JOGNN
R
ESEARCH
Human Papillomavirus and Cervical
Cancer Knowledge, Health Beliefs, and
Preventative Practices in Older Women
Kymberlee Montgomery, Joan Rosen Bloch, Anand Bhattacharya, and Owen Montgomery
ABSTRACT
Objective: To explore knowledge of Human Papillomavirus (HPV) and cervical cancer, health beliefs, and preven-
tative practices in women 40 to 70 years.
Design: Cross-sectional descriptive.
Setting: Three urban ambulatory Obstetrics and Gynecology offices connected with a teaching hospital’s Depart-
ment of Obstetrics and Gynecology in the Mid-Atlantic section of the United States.
Participants: A convenience sample of 149 women age 40 to 70.
Methods: To assess HPV and cervical cancer knowledge, health beliefs, and preventative practices a self-admin-
istered survey, the Awareness of HPV and Cervical Cancer Questionnaire was distributed to women as they waited for
their well-woman gynecologic exam.
Results: The mean knowledge score was 7.39 (SD
5
3.42) out of 15. One third of the questions about the rela-
tionship of HPV and risks for cervical cancer were answered incorrectly by more than 75% of these women. Although
most appreciate the seriousness of cervical cancer, they believed themselves not particularly susceptible.
Conclusion: There is a need for HPV and cervical cancer awareness and education for women older than age 40.
Women’s health care professionals are well positioned to act as a catalyst to improve HPV and cervical cancer
knowledge, health beliefs, and preventative practice to ensure optimum health promotion for all women.
JOGNN, 39, 238-249; 2010.
DOI: 10.1111/j.1552-6909.2010.01136.x
Correspondence
Kymberlee Montgomery,
DrNP, WHNP-BC, Drexel
University College of
Nursing & Health
Professions, 245 N. 15th
Street, Bellet 1029,
Philadelphia, PA 19102.
Keywords
human papillomavirus
HPV
cervical cancer
health beliefs
preventative practices
Accepted December 2009
G
enital Human Papillomavirus (HPV) infection
Contrary to previous studies that demonstrate a de-
cline in HPV prevalence as women age, recent
evidence suggests HPV prevalence follows a
bimodal distribution with a ¢rst peak around age
20 years and a second smaller peak around age
40 to 50 years (Bosch & Harper, 2006; Chan et al.,
2009; Ferreccio et al., 2004; Molano et al., 2002;
Munoz et al., 2004: Reis et al., 2006). It is not clear if
the second peak around age 40 to 50 years is due
to new cases of HPV or HPV that was acquired
many years before but not previously identi¢ed. Yet
new incident cases at these years are certainly
plausible. Fluctuations in relationship infrastructure
with increased divorce rates and in¢delity disclo-
sures, and acceptance of nontraditional sexual
relationships place women at age 40 and older
at an increased risk of sexually transmitted dis-
ease exposures (Baay et al., 2004; Castle et al.,
2005).
is the most common sexually transmitted dis-
ease in the United States (Centers for Disease
Control [CDC], 2009). Approximately 25 million
American women are currently infected with one or
more strains of low risk (types 6 and 11) and/or high
risk (types 16 and 18) HPV, while more than 6 million
new infections are being reported every year (Dun-
ne et al., 2007; Parkin, 2006). HPV infection is the
leading cause of cervical cancer (CDC). Recent ad-
vances demonstrate that HPV, spread primarily
through skin-to-skin contact during sexual activity,
is the etiologic agent of genital warts and can be
isolated in 99.7% of cervical cancer cases (Dunne
et al.; Munoz et al., 2002; World Health Organization,
2008). Cervical cancer is responsible for signi¢cant
morbidity and mortality worldwide, including an es-
timated 4,000 deaths in the United States in 2009
alone (National Cancer Institute [NCI ], 2008).
Kymberlee Montgomery,
DrNP, CRNP, is a certified
women’s health nurse
practitioner at Drexel
University College of
Medicine; the Women’s
Health Nurse Practitioner
Program Track Coordinator
at Drexel University
College of Nursing and
Health Professions; a nurse
colposcopist; and the
director of the
transdisciplinary
colposcopy course at
Drexel University,
Philadelphia, PA.
(Continued)
238
&
2010 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses
 R
ESEARCH
Montgomery, K., Bloch, J. R., Bhattacharya, A. and Montgomery, O.
Previous research has demonstrated limited knowl-
edge and health beliefs related to HPV in the
adolescent and college age populations (Baer, All-
en, & Braun, 2000; Burak & Meyer,1997; Daley et al.,
2008; Dell, Chen, Ahmad, & Stewart, 2009; Fried-
man & Shepeard, 2007; Ingledue, Cottrell, &
Bernard, 2004). However, despite emerging data
showing every four out of ¢ve women that reaches
50 years of age will be infected with HPV and that
35% of women who die of cervical cancer are older
than age 65 (CDC, 2009), women older than age 40
are rarely the focus of any initiatives on HPV and
cervical cancer awareness (Montgomery & Bloch,
2010). The median age of diagnosis for cervical can-
cer is approximately 47 years ([7]CDC). It is possible
that these women do not believe themselves at risk
of HPV infections and are less likely to practice pre-
ventive measures that can potentially minimize the
transmission of HPV infection and the development
of cervical cancer. In keeping with the goals of
Healthy People 2010 (to help individuals of all ages
increase life expectancy and improve quality of
life, as well as reduce the number of new cancer
cases and illness, disability, and death caused by
cancer) (U.S. Department of Health and Human
Services, 2000), it is essential to understand HPV
and cervical cancer knowledge needs of women
older than age 40.
Four out of five women who reach age 50 years will be
infected with HPV; 35% of women who die of cervical
cancer are older than age 65.
approved the ¢rst vaccine to prevent HPV acquisi-
tion and transmission for use in females age 9 to
26 years (CDC, 2009). After the Advisory Committee
on Immunization Practices (ACIP) put forth vacci-
nation recommendations in June of 2006, the CDC
began a multilevel national health campaign to ed-
ucate the targeted population of women in the
younger age group (Markowitz et al., 2007). In addi-
tion, the majority of cervical cancer cases and
deaths can be prevented through detection of pre-
cancerous changes in the cervix by cytology using
the Pap smear screening test.
The American College of Obstetricians and Gyne-
cologists (ACOG) (2009), the American Cancer
Society (ACS) (2007), and the U.S. Preventive Ser-
vices Task Force (USPSTF) (2007) have updated
Pap smear guidelines. ACOG recommends that cer-
vical cancer screening should begin at age 21years
(regardless of sexual history), because women
younger than age 21 are at very low risk of cancer.
In addition, ACOG advises Pap smears every 2
years for women between age 21 and 29 years and
every 3 years for women age 30 and older who
have had three consecutive negative cervical cy-
tology screening test results and who have no
high-risk Pap smear history. The ACS suggests that
all women should begin cervical cancer testing 3
years after they start having sex (vaginal inter-
course). A woman who waits until she is older than
age 18 to have sex should start screening no later
than age 21. The USPSTF continues to recommend
a conventional Pap test at least every 3 years, re-
gardless of age. These three organizations agree
that co-testing using the combination of cytology
plus HPV DNA testing is an appropriate screening
test for women older than age 30 years.
Background
More than 100 HPV genotypes are currently known,
and approximately 15 types of these potentially
cause cervical cancer (Gerberding, 2004; Roden
& Wu, 2006). Genotypes 16, 18, 31, and 45 are re-
sponsible for almost 80% of cervical cancer cases
worldwide, with genotype 16 accounting for almost
50% of these cases (Cli¡ord et al., 2006). Numer-
ous studies indicate that more than 90% of all HPV
infections in women clear within the ¢rst 2 years of
exposure (Gerberding Scheurer, Tortolero-Luna, &
Alder-Storthz, 2005; Schi¡man & Kjaer, 2003).
However, when the clearance of the virus is incom-
plete, HPV can progress to precancerous lesions
and cervical cancer (Koutsky et al., 2002; Jeurissen
& Makar, 2009; Schi¡man & Kjaer).
Joan Rosen Bloch, PhD,
CRNP, is an assistant
professor in the doctoral
Nursing Department in the
College of Nursing and
Health Professions and in
the Department of
Epidemiology in the School
of Public Health at Drexel
University, Philadelphia,
PA.
Since the inception of these campaigns and new
Pap smear screening recommendations, aware-
ness of HPV improved in women age 18 to 26 years
but remains decreased in women age 27 to 49 years
(Jain et al., 2009). There is a persistent HPVand cer-
vical cancer knowledge gap of women older than
age 26. Pairing this gap with the emerging evidence
of a second peak in HPV prevalence in older wo-
men where the preponderance risk of cervical
cancer resides generates the compelling reason
for investigating HPV and cervical cancer knowl-
edge, health beliefs, and preventative practices in
women older than age 40 years.
Anand Bhattacharya, MHS,
is a research associate at
Drexel University’s College
of Medicine, Philadelphia,
PA.
Acquisition of HPV infection of the genital tract usu-
ally occurs rapidly after sexual debut (Skinner et al.,
2008).Winer et al. (2003) showed a cumulative inci-
dence of HPV infection of about 40% in women
after ¢rst sexual intercourse or after sexual intimacy
with a new partner. Hence primary prevention strat-
egies in the preadolescent stage prior to HPV
exposure are optimal in eradicating cervical can-
cer.
Owen Montgomery, MD, is
the chairman of the
Department of Obstetrics
and Gynecology at Drexel
University College of
Medicine, Philadelphia, PA.
In 2006, the Food and Drug Administration
JOGNN 2010; Vol. 39, Issue 3
239
 R
ESEARCH
Human Papillomavirus and Cervical Cancer Knowledge
Theoretical Framework
This study was guided by the health belief model
(HBM). There are ¢ve core concepts: perceived
threat, perceived bene¢ts, perceived barriers, cues
to action, and self-e⁄cacy (Rosenstock, Strecher,
& Becker, 1994; Strecher & Rosenstock, 1997). The
HBM has been previously used to explain and pre-
dict health behaviors and health issues by focusing
on the knowledge, attitudes, and beliefs of individu-
als. As suggested by theories based on the HBM
(Strecher & Rosenstock), the likelihood that individ-
uals will take action to prevent illness depends on
their perception that they are personally vulnerable
to the condition, the consequences of the condition
would be serious, the precautionary behavior
e¡ectively prevents the condition, and the bene¢ts
of reducing the threat of the condition exceed
the costs of taking action (Redding, Rossi, Rossi,
Velicer, & Proschaska, 2000; Weistock et al., 2004).
Clinicians need to appreciate and understand their
patients’ health beliefs, especially in women age 40
and older who have not been the targets of the mar-
keting information about HPV, cervical cancer, and
the new vaccine.
found that among the general public, few women
are aware that an STI potentially causes cervical
cancer.
The purpose of this exploratory descriptive study
was to describe knowledge of HPV and cervical
cancer, health beliefs, and preventative practices
of women age 40 to 70 years. In addition, the study
explored the relationships among knowledge of
HPV and cervical cancer and self-reported health
beliefs among women age 40 to 70 years.
Methods
Design
This study was a cross-sectional descriptive de-
sign. Anonymous data were collected over a 2-
month period in 2008 using a self-administered
pen-and-paper questionnaire.
Setting and Sample
A convenience sample of women age 40 to 70 years
was recruited from the waiting rooms of three am-
bulatory obstetrics and gynecology o⁄ces of a
large metropolitan university hospital in the Mid-At-
lantic section of the United States. All three o⁄ces
were used in an attempt to get a racially heteroge-
neous sample in this urban area that has rate of
cervical cancer 1.7 times higher than the national
rate (NCI, 2008). The inclusion criteria were women
age 40 to 70 years, presenting to their health care
provider for an annual checkup, and who did not
have a past or present history of HPV or cervical
cancer.
Previous Studies of HPV
Knowledge
Knowledge related to HPV, its relationship to cervi-
cal cancer, and cervical cancer itself is improving
but continues to have de¢cits in younger and
older women (Denny-Smith, Bairan, & Page, 2006;
Holcomb, 2004; Ingledue et al., 2004; Montgomery
& Bloch, 2010; Jain et al., 2009). In the Denny-Smith
et al. study, the Awareness of HPV and Cervical
Cancer tool was distributed to a convenience
sample of 240 female nursing students, age 19 to
58 years with a mean age of 30 (SD
5
8.48) enrolled
in a baccalaureate nursing program. The results
indicated a lack of knowledge combined with
low perceptions of susceptibility and seriousness
of HPV and cervical cancer may make college
women more likely to contract sexually transmitted
infections (STIs) including HPV and therefore more
susceptible to cervical cancer. Numerous recent
studies that examined public knowledge of HPV
and this link to cervical cancer agree that public
awareness of HPV’s connection to cervical cancer
remains suboptimal (CDC, 2009; National Associa-
tion of Nurse Practitioners in Women’s Health
[NPWH][27][35][38], 2009; Sherris et al., 2006;
Vanslyke, Baum, Plaza, Otero, & Wheeler, 2008).
The most recent survey from the NPWH suggests
that women still do not have a clear understand-
ing about the relationship between HPV and
cervical cancer. Marlow, Waller, and Wardle (2009)
The sample size required for this study was guided
by a power analysis using the software program
G
Power (Version 3.0.10, Dusseldorf, Germany).
The power analysis was based on the correlation
analysis between the subscales knowledge, sus-
ceptibility, and seriousness. Small to medium e¡ect
size (Pearson’s r
5
0.23) was postulated in keeping
with Cohen’s (1992) recommendation for Pearson
correlation. Power was set to 0.80, meaning there
would be an 80% probability of reaching statistical
signi¢cance if the subscales were correlated. In
this study, for a signi¢cance level of
a 5
0.05
(two tailed), with an e¡ect size of 0.23, to achieve
a power of 0.80, a total sample size of 145 partici-
pants were required. To account for attrition due to
missing data, we recruited an additional 10% for a
total sample of 160. Out of 160 women who received
study packets, 149 completed questionnaires that
were returned in the sealed envelopes ; 11 question-
naires were incomplete and not used in these
analyses.
240
JOGNN, 39, 238-249; 2010. DOI: 10.1111/j.1552-6909.2010.01136.x
 R
ESEARCH
Montgomery, K., Bloch, J. R., Bhattacharya, A. and Montgomery, O.
Procedure
Following approval by the university Institution Re-
view Board (IRB), the study began by training a
research assistant (RA; receptionist) at each of the
three o⁄ces.The training entailed using data on the
practice management program to identify potential
eligible participants when women are checked in
for their visits, inviting potential participants, and
keeping all data anonymous by sealing all enve-
lopes and placing them in the research bin in a
secured drawer or cabinet based on the speci¢c of-
¢ce. At each of the three sites, there were £yers
posted on the walls and a trained RA invited partic-
ipants if they met eligibility. If the patient met the two
requirements of age and the reason for the visit
(well-women check up), she was given a sheet to
read to further determine eligibility (exclusion crite-
ria if she had a history of HPV or cervical cancer).
After she read the sheet, the RA asked if she was el-
igible. If she said yes, she was given the survey
packet with a cover letter that accompanied the
packet. The cover letter contained a brief descrip-
tion of the research project, assurance of
anonymity, the voluntary nature of participation,
and IRB contact information. Completion of the sur-
vey acted as consent for participation. Once the
survey was completed, it was placed in a sealed en-
velope to be returned to the researcher such that no
identity was disclosed.
onstrated by subsequent studies that used the
questionnaire on women from other age groups
(Denny-Smith et al., 2006). Using the same tool
allowed comparison of results from this study to
other published studies (Denny-Smith et al.; Ingle-
due et al ; McKeever, 2008).
The knowledge portion of the questionnaire con-
sists of 15 multiple-choice items, with each
question permitting only one response. The knowl-
edge score for this instrument ranges from 0 to 15
with higher scores indicative of more knowledge of
HPV and cervical cancer. The perceived threat por-
tion of cervical cancer consists of 15 questions,
using a 5-point Likert-type scale ranging from 1
(strongly agree)to5(strongly disagree). Nine of
the 15 questions relate to perceived susceptibility
and have a possible subtotal score range from 9 to
45. The remaining six questions relate to perceived
seriousness and have a potential score that ranges
from 6 to 30. Higher scores imply greater level of
perceived susceptibility and seriousness about
HPV and cervical cancer. The last six questions fo-
cus on individual sexual behaviors, risk factors,
and history of pap smears and are multiple-choices
categorical variables.
Ingledue et al. (2004) supported content validity of
the instrument by using consensual validity via a
panel of experts that represented several health
professionals including two gynecologists, two pro-
fessors of health education, and a medical
professional from the Breast and Cervical Cancer
program (Ingledue et al.). The authors also deter-
mined stability of the instrument over a 10-day
period through test^retest reliability procedure.
They reported that the instrument has high test^re-
test reliability for knowledge (r
5
0.90), perceptions
and beliefs (r
5
0.95), and preventative behaviors
(r
5
0.90) (Ingledue et al.). Internal consistency reli-
ability was not reported in the study by Ingledue et
al. For the current study, the internal consistency re-
liability for the Knowledge subscale was adequate
(Cronbach’s
a 5
0.77), but unacceptably low for
the Susceptibility subscale (
a 5
0.49) and Serious-
ness subscale (
a 5
0.20). This low reliability makes
any conclusions based on these subscales tenta-
tive at best. Quantitative data were coded and
entered into SPSS-PC 16.0 (SPSS Inc, Chicago, IL)
and stored on a secured computer used for re-
search purposes only. Descriptive statistics
including frequencies for categorical variables and
measures of central tendency (M) and variances
(SD) for continuous variables were used to describe
the HPV/cervical cancer knowledge, health beliefs,
and preventative practices in women age 40 to 70
Measures
Sociodemographic variables collected included
age, race, education, health insurance status, relig-
ious a⁄liation, marital status, and income level.
HPV and Cervical Cancer Knowledge,
Health Beliefs, and Preventative Practices
With permission from the authors, the Awareness of
HPV and Cervical Cancer Questionnaire (Ingledue
et al., 2004) was used to measure knowledge and
beliefs, as well as preventative measures in regards
to HPV and cervical cancer. Ingledue et al. devel-
oped this self-administered 36-item questionnaire
based on the HBM (Glanz, Rimer, & Lewis, 2002) to
investigate HPV/cervical cancer knowledge, health
beliefs, and perception, and preventative measures
in college-age women. The tool was used in this
study because it was speci¢cally designed for HPV
and cervical cancer awareness and congruent
to the HBM that guided the study. Although
the questionnaire was originally used on college
age women, a panel of experts (obstetricians/gyne-
cologists, physicians, and nurse practitioners)
reviewed the questions concluding they were
generalizable to women of all age groups as dem-
JOGNN 2010; Vol. 39, Issue 3
241
R
ESEARCH
Human Papillomavirus and Cervical Cancer Knowledge
years. Pearson product^moment correlations were
calculated to describe the relationship among
HPV/cervical cancer knowledge,
Table 1: SocioDemographic
Characteristics of the Sample (
N
5
149)
susceptibility,
and seriousness in these women.
SocioDemographic
Characteristics
Mean (SD)
To further understand knowledge, health beliefs
(perceived susceptibility and perceived serious-
ness) and preventative practices in women age 40
to 70, these women were divided into age groups
by decade: 40 to 50, 51 to 60, and 61 to 70 years. Fol-
lowing testing for assumptions, a one-way analysis
of variance (ANOVA) was conducted to compare
knowledge and health beliefs among the three sub-
groups. If the ANOVAs were signi¢cant, post hoc
analyses were conducted using a Bonferroni ad-
justment. Preventative practices were compared
among the three subgroups using the chi-square
analysis. A Fishers Exact test was used when as-
sumptions of chi-square were not met. Level of
signi¢cance for all tests were set at
a 5
0.05.
Ageçmean (SD)
50.86 (7.6)
Sexual partnersçmean (SD)
1.45 (1.4)
Race/ethnicity
n (%)
White (Caucasian/
Non-Hispanic)
92 (61.7)
African American/
Non-Hispanic
37 (24.8)
Asian/Hawaiian/Paci¢c
Islander
6(4)
Hispanic/Latino
9 (6)
Other
5 (3.4)
Education
Results
Sample Characteristics
The sociodemographics of the participants are de-
tailed inTable 1. The average age of the sample was
50.86 (SD
5
7.60) years old. Of the 149 women, one
half reported being married (n
5
75), more than
80% had private health insurance (n
5
126) and
more than 30% (n
5
47) had an annual household
income of $80,000 and more.
High School graduate
38 (25.5)
Somecollegecourses
43(28.8)
College graduate
64 (43)
Other
3 (2)
Missing
1 (0.7)
Marital status
Single
30 (20.1)
Knowledge
The mean score for knowledge, measured by the 15
items on the Awareness of HPVand Cervical Cancer
Questionnaire was 7.39 (SD
5
3.42) out of a possible
15.Table 2 represents the frequency of correct and in-
correct responses for each item of the Knowledge
subscale of the Awareness of HPV and Cervical
Cancer Questionnaire. It should be noted that more
than one half of the women responded incorrectly
to knowledge questions 1, 2, 3,10,12, and15.
Married
75 (50.3)
Widowed
7 (4.7)
Divorced
24 (16.1)
Living w/signi¢cant other
12 (8.1)
Missing
1 (0.7)
Religion
Christian
41 (27.5)
Catholic
65 (43.6)
Health Beliefs
Health beliefs were measured under the subdimen-
sions of perceived threat: perceived susceptibility
and perceived seriousness. For susceptibility, mea-
sured by nine items on the Awareness of HPV and
Cervical Cancer Questionnaire (Ingledue et al.,
2004) the mean score was 26.11 (SD
5
4.64) out of
a possible 45, and ranged from18 to 44. Table 3 rep-
resents the frequency and percentage of responses
for each item for susceptibility in the questionnaire.
More than 50% of women in this age group report-
edly worry about getting cervical cancer, however
just more than 32% are concerned about being in-
Jewish
18 (12.1)
Muslim
2 (1.3)
Other
22 (14.8)
Missing
1 (0.7)
Income level
0 to 20k
10 (7.0)
21 to 40k
20 (13.4)
41 to 60k
37 (24.8)
61 to 80k
24 (16.2)
242
JOGNN, 39, 238-249; 2010. DOI: 10.1111/j.1552-6909.2010.01136.x
    [ Pobierz całość w formacie PDF ]