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The burden of human papillomavirus (HPV) and HPV-related diseases, particularly cervical cancer, are still very high in Africa. Unlike HIV/AIDS, the burden is still largely unrecognized in several African countries. HPV is diagnosed in more than 90% of cervical cancers, which are the most common cause of cancer death among women in Africa. Overall, HPV infection and related diseases are more prevalent in developing countries with minimal resources to tackle them. For instance, Africa is characterized by low access to health services and cancer care in particular.
- human papillomavirus
- school-based intervention
- adolescents
- life-course approach
1. Awareness and Knowledge of Human Papillomavirus and Cervical Cancer
1.1. Extent of Knowledge Pre-Intervention
Before the intervention, results obtained from the scoping review are indicative of low awareness of Human Papillomavirus (HPV) and its vaccination [1]. Likewise, understanding of HPV, cancers caused by HPV, its mode of transmission, the HPV vaccine [1][2], that boys could use the HPV vaccine, the sexual infectivity nature of HPV and diseases it causes was inadequate among Africans [2]. Similarly, awareness of cervical cancer (CC) [2] and its prevalence, awareness of the risk factors as well as the broad categories of cervical cancer and HPV was also low in Africa [2][3].
At baseline, sufficient knowledge about CC could not be established, as evidenced by the low overall knowledge score obtained by the majority of the participants [1][3]. In specific terms, knowledge of the various dimensions of cervical cancer such as its symptoms [2][4]. screening [2] and prevention including vaccination was poor prior to educational interventions [4]. Furthermore, an understanding of the causative organism, risk factors [1][3], at-risk populations, and treatment of CC was lacking [3]. Conversely, good knowledge of CC prevention was shown in one of the studies reviewed where adequate knowledge of CC prevention was reported for a group of participants (seminar cohort) but found to be insufficient in another group (school cohort) in the same study. This low knowledge trend was observed in different subsets of the African population such as among mothers [4] and high school students [1].
1.2. Change in Knowledge Post-Intervention
Some level of knowledge upswing was reported following educational interventions on HPV and CC in different African settings [1][2][3][4]. Where assessed, a positive change in the global knowledge score was observed after intervention [1][3]. Awareness of CC [2][3] and its prevalence [3], improved greatly post-intervention. Knowledge of CC causative organism, risk factors, population subgroup more predisposed to CC [3], risk factors [2], its major symptoms, screening (Pap smear test) [2][4] and vaccination [4] improved greatly following the intervention.
Likewise, understanding of the STI nature of HPV and awareness about the HPV vaccine became better, whereas knowledge of diseases associated with HPV remained poor [2]. In South Africa, a noticeable positive change in knowledge was recorded among mothers/guardians of school girls [4] and high school learners (73.38%) [1]. While in Nigeria, knowledge of early symptoms of CC, Pap smear, and HPV vaccine remained low among students following an educational intervention. Although a slight but low increase in knowledge of CC risk factors and understanding of CC symptoms was observed [5].
2. Determinants of Awareness and Knowledge of Cervical Cancer and Human Papillomavirus: Pre- and Post-Intervention
At baseline, the determinants of awareness and extent of knowledge about cervical cancer were mostly demographic factors. For instance, cervical cancer awareness was linked with gender and age. Whereas an understanding of CC symptoms was also linked to demographic factors (these include gender (female), level of study (3rd year and above) and family income (5000>) [2], an understanding of the CC risk factors was predicted by gender (female) and family income (5000>) only. Maternal education (low level) was linked to poor knowledge of CC risk factors. Paternal educational level was directly associated with good knowledge of CC screening [2].
As for HPV knowledge at baseline, this was positively associated with age and CGPA. The lower the age and CGPA, the poorer the knowledge. Appropriate understanding of HPV vaccination was associated with higher family income and vice versa [2]. For knowledge change post-intervention, differences in age, gender, level of study and place of residence were important determinants. Female and older students had better knowledge of HPV than their male and younger colleagues, respectively [1].
The post-intervention change in HPV understanding was significantly influenced by the year of study, level of education, and CGPA. Those studying at the postgraduate level, second year and above, and students with higher CGPA had a better understanding of HPV [2].
The improvement in cervical cancer global knowledge score was a function of a higher level of study (>3rd year), higher CGPA and urban residence [2]. While another study found a positive relationship between adequate general knowledge of CC and poor rural residence [1]. Good understanding of the symptoms of CC after the educational intervention was determined by older age, year of study (3rd year), and maternal job status (employed) [2]. Understanding of CC screening was predicated on being an urban resident, being a postgraduate student and year of study. The level of study (4th year >) also determined the understanding of CC vaccination [2]. Being ‘engaged’ either as attendees or handout readers during interventions was a determinant of knowledge improvement on CC screening, predisposing factors and HPV vaccine [5].
3. Impact of School-Based Interventions on Health Behavior
Vaccine acceptance by parents/guardians and their children/wards was indicated through consent and assent by the parents and children, respectfully. Parents’ participation in a health education event had a positive influence on consent to vaccinate their children/wards [4]. Most studies reported a high rate of vaccine acceptability with a consent rate ranging between 59% [6] and 59.7% [4] as reported in South Africa. In Kenya, a rate of 88.1% was recorded [7].
Although not all consent did translate into the uptake of the vaccine’s first dose as a high baseline, vaccine acceptance failed to match vaccine uptake after intervention [4][7] in some settings. Vermandere et al. (2014) observed an uptake of 31.1% in Kenya, where negative vaccine behavior occurred among 17.7% of the participants and 51.2% experienced difficulties which prevented them from getting their daughters vaccinated.
Conversely, the total rate of uptake of the first vaccine dose among those who consented was quite high in some countries. In South Africa, this ranges from 99.2% [6] to 99.3% [4], while 89% and 95% of school girls indicated being vaccinated in Rwanda and Bhutan, respectively. A high proportion (**) of them had more than one dose of the vaccine [8].
Complete/sufficient vaccination (a minimum of two doses within six months) was reported for the majority (91.6%) of those who initiated it in South Africa, this represents 53.7% of the targeted population [6]. Similarly, Dreyer et al. (2022) observed a completion rate of 90.5% in the same country. Some local differences in the rate of vaccine completion were observed, 93.3% in the Western Cape and 82.6% in Gauteng. [6]. While Dreyer et al. indicated that the number of vaccine doses influenced its completion as three doses attracted a slightly lower rate (91.6%) than two doses (95.9%) [4]. Where indicated, an impressive proportion of the vaccinated population (87.8%) received all three doses of the HPV vaccine [6].
Some negative screening behavior was also found among some mothers whose rate of self-screening uptake was comparatively lower than the initial acceptance [4]. Contrariwise, in a similar population, a good attitude towards CC screening as well as a positive attitude towards and trust in vaccines was previously observed by researchers [9].
4. Determinants of Post-Intervention Health Behavior: Screening and Vaccination
Some of the post-intervention health behavior expected in the studies include an increase in the rate of CC screening, vaccine acceptability and uptake. Certain underlying factors were highly influential in these health behaviors across settings. These determinants were documented by only a few of the studies sampled.
In South Africa, Dreyer et al. reported that invitation to partake in a screening exercise, especially at a health training, access to screening facilities and scoring high in knowledge tests were significantly associated with positive screening behavior. Additionally, receiving a self-screening kit at home or at a health education program was statistically associated with screening uptake than visiting a health facility [4]. Parental informed consent determined vaccine uptake, while the number of required vaccine doses was also positively associated with vaccine completion [4].
As for vaccine behavior, individual characteristics did not reflect vaccine acceptance in Kenya [7]. However, baseline concerns about the HPV vaccine, such as its efficacy, side effects, and possible effects on fertility, negatively affected vaccine acceptance among Kenyans. Likewise, apprehensions about wrong vaccine administration, foreseeing partner’s disapproval, as well as religion (Muslims accepted less) determined vaccine acceptance. Furthermore, concerns about child age, inadequate information about CC, and the belief that vaccine promotes unprotected sex negatively affected vaccine acceptability in the studied group [7].
The authors further observed that older age was positively associated with vaccine acceptance [7]. Moreover, having an urban background, baseline awareness of CC, and vaccine acceptance were all positively linked to vaccine uptake [7]. Prior knowledge or awareness of CC and partner disapproval were the major predictors of vaccine uptake [7]. In contrast, hindrances to vaccine uptake include lack of information/invitation about the vaccine (where and when to vaccinate), vaccine disapproval by significant others (e.g., partner and the daughter herself), non-availability, fear of side effects, time constraint, and failure to recall the vaccination [7].
This entry is adapted from the peer-reviewed paper 10.3390/venereology2010004
References
- Mbulawa, Z.Z.A.; Somdyala, N.I.; Mabunda, S.A.; Williamson, A.L. Effect of Human Papillomavirus (HPV) Education Intervention on HPV Knowledge and Awareness Among High School Learners in Eastern Cape Province of South Africa. J. Cancer Educ. 2021.
- Indracanti, M.; Berhane, N.; Minyamer, T. Factors associated with pre-and post-educational intervention knowledge levels of hpv and cervical cancer among the male and female university students, northwest ethiopia. Cancer Manag. Res. 2021, 13, 7149–7163.
- Sadoh, A.E.; Okonkwobo, C.; Nwaneri, D.U.; Ogboghodo, B.C.; Eregiea, C.; Oviawe, O.; Famuyiwa, O. Effect of Peer Education on Knowledge of Human Papilloma Virus and Cervical Cancer among Female Adolescent Students in Benin City, Nigeria. Ann. Glob. Health 2018, 84, 121–128.
- Dreyer, G.; Botha, M.H.; Snyman, L.C.; Visser, C.; Burden, R.; Laubscher, N.; Grond, B.; Richter, K.; Becker, P.J.; Harvey, J.; et al. Combining cervical cancer screening for mothers with schoolgirl vaccination during human papillomavirus (HPV) vaccine implementation in South Africa: Results from the VACCS1 and VACCS2 trials. Int. J. Gynecol. Cancer. 2022, 32, 592–598.
- Ifediora, C.O.; Azuike, E.C. Targeting cervical cancer campaigns on teenage high schoolers in resource-limited economies: Lessons from an intervention study of Nigerian senior secondary school girls. Fam. Pract. 2019, 36, 600–606.
- Botha, M.H.; Van der Merwe, F.H.; Snyman, L.C.; Dreyer, G. The Vaccine and Cervical Cancer Screen (VACCS) project: Acceptance of human papillomavirus vaccination in a school-based programme program in two provinces of South Africa. S. Afr. Med. J. 2015, 105, 40–43.
- Vermandere, H.; Naanyu, V.; Mabeya, H.; Vanden Broeck, D.; Michielsen, K.; Degomme, O. Determinants of acceptance and subsequent uptake of the HPV vaccine in a cohort in Eldoret, Kenya. PLoS ONE 2014, 9, e109353.
- Baussano, I.; Sayinzoga, F.; Tshomo, U.; Tenet, V.; Vorsters, A.; Heideman, D.A.M.; Gheit, T.; Tommasino, M.; Umulisa, M.C.; Franceschi, S.; et al. Impact of Human Papillomavirus Vaccination, Rwanda and Bhutan. Emerg. Infect. Dis. 2021, 27, 1–9.
- Dreyer, G.; Van Der Merwe, F.H.; Botha, M.H.; Snyman, L.C.; Constant, D.; Visser, C.; Harvey, J. School-based human papillomavirus vaccination: An opportunity to increase knowledge about cervical cancer and improve uptake of screening. S. Afr. Med. J. 2015, 105, 912–916.
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