Knowledge of human papillomavirus vaccines among university students in Angola

Cervical cancer is the first most common cancer among women in Angola, and the human papillomavirus (HPV) is an important causative agent of the disease.1 We now have vaccines available to prevent HPV infection. Angola does not have an HPV vaccination policy or screening methods. There is a need to study the awareness of HPV vaccination and take steps to improve the use of vaccination.

Cervical cancer accounts for 37% of cancers among women in Angola. A total of 2,949 new cases of cervical cancer were diagnosed in 2018.2 It is considered the first leading cause of female cancer-related deaths in Angola.2

Human papillomavirus (HPV) infection is now a well-established cause of cervical cancer and there is growing evidence that HPV is a relevant factor in other anogenital cancers (anus, vulva, vagina, and penis) as well as head and neck cancers. HPV types 16 and 18 are responsible for about 70% of all cervical cancer cases worldwide. HPV vaccines that prevent HPV 16 and 18 infections are now available and have the potential to reduce the incidence of cervical cancer and other anogenital cancers.3

In a study conducted among Iranian women in 2013-16, the prevalence of HPV infection was 29.3%.6 In the same study, among HPV-positive individuals, the high and low-risk HPV subtypes were found 67.2% and 52.0%, respectively.6 A study was conducted in the rural Philippines, in 2020, among the community that inferred that only 13.9% had undergone cervical cancer screening.7 In a study conducted among Thai women, in 2020, 46% of participants had insufficient knowledge about HPV infection and vaccination.8

Recent advances in technology have led to the introduction of the HPV vaccine to prevent HPV infection, which will directly help reduce the incidence of cervical, anogenital and genital warts.

Vaccination is also recommended for boys as it is also implicated in penile, rectal, and oral cancer. Men also play a role in the transmission of HPV infection to women.9

As the HPV vaccine is a recent introduction and is targeted at the 9 to 26 age group, awareness of this vaccine in the general population appears to be lower. 9-14 years is the ideal age to administer this vaccine, as it provides maximum immunogenicity of the vaccine at that age.10

In a study conducted in Mangalore with medical students, 78.35% of students were aware of cervical cancer prevention; 82.47% knew that cervical cancer is caused by a virus; 74.22% were aware of the availability of the vaccine.11 In a study carried out in Manipal with medical students, only 28.4% of male students knew that there is a need for vaccination in men.12 The HPV vaccine is a more recent addition to the universal immunization schedule. Therefore, your awareness is lower compared to other vaccines.

Assessing knowledge about vaccination among university students helps us to understand the level of awareness about it among future physicians. Knowledge about the symptoms of cervical cancer can help with the early detection and treatment of cervical cancer. After discovering the vaccination status, it will guide us to conduct proper awareness programs and motivate students to get vaccinated.

This study was carried out with the following objectives:

A cross-sectional study was conducted on students from different universities and faculties of medicine, nursing, law, administration, psychology, engineering, and science in Angola. The inclusion criteria were students willing to participate in the study, attending the 2^nd to the 4^th degree of graduation, and aged between 18-26 years. Exclusion criteria were those who were unwilling to participate in the study.

A sample of 106 students was chosen (2^nd to 4^th students) (Table 1).

The questionnaire was prepared using the google forms platform, consisted of 10 questions, of which 4 questions assessed knowledge, 4 questions assessed attitude, and 2 questions assessed practice concerning HPV infection and HPV vaccination. Were of the multiple-choice type, the participants were asked to choose an answer. The questions about attitude and practice were yes or no questions.

Knowledge was assessed through questions about risk factors, causal agents, cervical cancer screening methods. In the question about risk factors, 4 correct risk factors were given and the inference was made about each risk factor chosen in percentage. Likewise, the question: cancers most common among women in Angola; was rated 2 out of 4 correct answers in the options.

Questions about knowledge of vaccine availability, if the vaccine is given in health facilities; were used to assess knowledge about the HPV vaccine with a yes or no type of answer. The question about the right age group for vaccination had 1 in 4 correct answers in the options.

Attitude was assessed based on willingness to be vaccinated and to recommend the vaccine to a female relative with a yes or no type of response. Percentages based on correct answers were calculated and compared for each question separately for male and female students.

Our study aimed to assess the knowledge and acceptability of the HPV vaccine among university students. According to our study, 4 (12%) men and 72 (99%) women knew that the HPV virus causes cervical cancer. To compare, in a study by Al-Darwish et al. (2014)9 in Saudi Arabia, among medical students, 45% of men and 53.2% of women were able to identify HPV infection as the cause of cervical cancer. This shows that there is a big difference in knowledge about the causal agent between the two studies with more students knowing in the present study.

In the current study, 59 (82%) women and 14 (44%) men knew that the HPV vaccine is available at 2 private hospitals in Luanda. A study conducted by Pandey et al. (2012)7, in Manipal, among medical students showed that 65.7% of men and 83.1% of women were aware of the availability of the HPV vaccine.

A higher percentage of male students were aware in the current study when compared. In a study conducted by Borlu et al. (2016)10, in Turkey, among undergraduate university students, 160 (62.5%) medical students were aware of the availability of the HPV vaccine compared to 116 (66.5%) medical students in our study.

The current study shows that 32 (99%) men and 73 (100%) women were willing to be vaccinated. In addition, 32 (92%) men and 73 (100%) women were willing to recommend the vaccine to a female relative. This indicates that there is a lack of awareness among men regarding the recommended vaccination for men. This is also reflected in the fact that only 99% of men were willing to vaccinate for themselves, compared to 99% of men willing to advise a female relative to vaccinate. In a study conducted by Fu et al. (2014)12 among medical students in ChongQing, China, 57.2% of men and 78.5% of women were willing to receive or advise HPV vaccination.

In the present study, none male students had received the partial course of vaccination, with 0 of the men had received the full vaccination. 9 (13%) women received full vaccination with 1 (0.73%) having received a partial course of vaccination. In a study conducted by Berenson et al. (2017).13 In the US, among 231 medical students, 81 (66.4%) female students and 16 (14.7%) male students reported having started the vaccine. Among all participants in our study, only 14 (9.3%) of the participants had received full vaccination compared to 75 (35.2%) students with complete vaccination status, according to a study by Afonso et al. (2017)14 in the US among 213 medical students. In the same study, partially vaccinated students were 19 (8.9%), compared to 2 (1.33%) in this study.

Regarding risk factors for cervical cancer, 8 (24%) male students and 39 (53%) female students were able to correctly identify early marriage, early childbirth, multiple sexual partners, and infections such as risk factors for cervical cancer.

The Pap smear as a screening method for cervical cancer was known by 90.1% of participants in a study by Maharajan et al. (2015)15 in Malaysia among 305 medical students. In our study, 51 (69%) of the participants demonstrated this knowledge. This knowledge seems comparable in both studies.

When asked about the need for screening for cervical cancer after vaccination, 106 (100%) of the students responded positively in the present study. In a study conducted by Yam et al. (2017)11, in Hong Kong, among 420 medical and non-medical students, 88 (86.3%) medical students below the 3^rd year and 141 (99.3%) medical students from the 3^rd year onwards have this knowledge. These data appear to be similar to our study. More studies can be carried out to advocate with the Ministry of Health for the implementation of the vaccine in the national vaccination calendar.

The present study concludes that there is not a good knowledge of university students about the HPV vaccine, meaning the availability of the vaccine, the right age group for vaccination, and the recommended vaccination for men need to be improved. Vaccination status is poor among men and women because it is not on the national vaccination calendar. Angola does not have a vaccination policy against HPV or screening methods, we believe that this is the reason for the results found. The government through the Ministry of Health must incorporate the HPV vaccine in the vaccination calendar.