- Email: [email protected]
College Men's Knowledge, Attitudes, and Beliefs about the Human Papillomavirus Infection and Vaccine
Journal of Adolescent Health 45 (2009) 535–537
Adolescent health brief
College Men’s Knowledge, Attitudes, and Beliefs about the Human Papillomavirus Infection and Vaccine Jennifer D. Allen, Sc.D., M.P.H., R.N.a,b,*, Heidi Collins Fantasia, Ph.D., R.N., W.H.N.P.-B.C.a, Holly Fontenot, M.S., R.N., W.H.N.P.-B.C., S.A.N.E.a, Stephen Flaherty, M.P.H.b, and Jeans Santanaa a William Connell School of Nursing, Boston College, Chestnut Hill, Massachusetts Center for Community-Based Research, Dana-Farber Cancer Institute, Boston, Massachusetts Manuscript received January 3, 2009; manuscript accepted May 28, 2009
b
See Editorial p. 427 Abstract
Men enrolled in an urban university participated in focus groups (k ¼ 6; n ¼ 45) to explore knowledge about human papillomavirus and attitudes toward prophylactic vaccine. Results suggest that regardless of whether vaccines become available to men, educational efforts should include them, as men tend to have many misconceptions and do not perceive themselves to be vulnerable. Ó 2009 Society for Adolescent Medicine. All rights reserved.
Keywords:
Human papillomavirus; HPV; College health; Men’s health
Human papillomavirus (HPV) is the most common sexually transmitted infection (STI) in the United States (U.S.). HPV is now recognized as a causative factor in cervical cancer in women and male genital disease. Oncogenic HPV types are associated with 93% of anal cancers [1] and 40% of penile cancers [2]. Among sexually active men 18–40 years of age, the prevalence of anogenital HPV may be as high as 72% [3]. Nononcogenic HPV types are believed responsible for 90% of genital warts and are associated with substantial morbidity, costing more than $400 million in the U.S. in 2003 [4]. Data have shown that men experience genital warts in longer duration than women [5]. Prophylactic vaccines are now approved for use among females in the U.S. [6]. Vaccine is licensed for male use in Mexico and Australia, and it is anticipated that it will soon become available to men in the U.S. [7]. The viral strains covered in both existing vaccines (types 16, 18) could drastically reduce the occurrence of anogenital warts in men, whereas the quadrivalent vaccine, which additionally covers types 6,11, could prevent up to 90% of genital warts [4]. Few studies have examined men’s attitudes toward the HPV vaccine since it was licensed for use in the U.S. [8,9].
The purpose of this study was to gain a better understanding of men’s knowledge and attitudes toward the HPV vaccine, to inform the development of effective population-based intervention strategies.
*Address correspondence to: Jennifer D. Allen, Sc.D., M.P.H., R.N., William Connell School of Nursing, Boston College, 140 Commonwealth Avenue, Boston, MA 02167. E-mail address: [email protected]
Knowledge and awareness
Methods Six focus groups with students 18–22 years of age (n ¼ 45) were conducted at a large private university in the Northeast. Students were recruited through campus advertisements. A male moderator facilitated using a semistructured guide (Table 1). Discussions were audiotaped and transcribed verbatim, and initial coding categories were developed. Open codes were collapsed into higher-order categories that reflected the predominant emergent themes. Data were collected until the point of saturation. Study protocols and procedures were approved by the University Institutional Review Board. Results Demographic data on participants are presented in Table 2. Dominant themes are presented below.
There was a high level of recognition of HPV as a STI. Men recognized that infection was more common among those
1054-139X/09/$ – see front matter Ó 2009 Society for Adolescent Medicine. All rights reserved. doi:10.1016/j.jadohealth.2009.05.014
J.D. Allen et al. / Journal of Adolescent Health 45 (2009) 535–537
536 Table 1 Question guide for focus groups Topic area
Sample questions
Health practices and concerns
What types of health issues do you think concern college men? What do you do to take care of your health? (probes: diet, physical activity, smoking, sexual health)
Knowledge and awareness of HPV
What do you know about sexually transmitted infections? Have you ever heard of HPV? If yes, what comes to your mind when you think of HPV? What do you know about HPV (probes: transmission, health consequences, symptoms, diagnosis, treatment)? How did you first hear about HPV
Knowledge and awareness of the HPV vaccine
Have you ever heard of a vaccine to prevent HPV? If yes, what have you heard? (probes: What does it do? Who is it for?) How did you first hear about the vaccine?
Vaccine acceptance- self and others
If the vaccine were available to you, would you choose to get it? Why or why not? Would you recommend the vaccine to your female friend(s), sister or (female) your significant other?
Suggested intervention strategies
Would college men be interested in learning more about HPV? What specifically do you think they would want to know? How would this information best be communicated?
with multiple sexual partners (‘‘guys who jump around’’) and those who do not use condoms (‘‘you gotta always wrap it up’’). Many recognized the connection with cervical cancer, but none associated HPV with anal, penile, or oropharyngeal cancer. Participants were aware that HPV was a common virus with no cure, but few understood the consequences of different viral strains or that the virus could be transmitted without symptoms. Most were incorrect in their descriptions of symptoms of infection (‘‘weird discharges and burning’’) and incorrectly believed diagnosis was made by ‘‘blood or urine.’’ None could name any form of treatment for genital warts. Low perceived susceptibility and severity Many did not know that men as well as women were susceptible to HPV or did not feel that HPV was a severe infection (‘‘I think it’s more of a joke’’). The majority acknowledged that infection could be serious for women, and referred to HPV as a ‘‘woman’s disease.’’ Those who knew about the link with cervical cancer did not feel that either the cancer or the infection were severe (‘‘you don’t hear a lot of death associated with HPV’’). Some cited condoms as protective measure but did not realize that condoms are only partially protective.
Table 2 Sample characteristics (n ¼ 45)
Race/ethnicity Caucasian/white African-American/black Hispanic/Latino Asian Other Year in school Freshman Sophomore Junior Senior Currently sexually active Yes No Missing
n
%
23 11 5 3 3
51 24 11 7 7
6 4 14 21
13 9 31 47
32 12 1
71 27 2
Uncertainty about the vaccine Many knew that a vaccine is available for women for prevention of cervical cancer. When asked about receiving the vaccine if it became available to men, apprehension was voiced about cost, accessibility, safety, and side effects. Although unsure for themselves, participants believed that women in general would benefit (‘‘better safe than sorry’’). However, reservations were expressed (‘‘there’s been so many things that women have taken that have supposed to help them which have ended up being negative for them’’). Contextual factors and risk ‘‘Hooking up’’ was a strong and pervasive theme. Men expressed that it was ‘‘safe’’ to have sex with students at their school, but individuals not enrolled at the school or casual acquaintances were seen as more risky (‘‘I feel like you’re a little safer [with class mates] than with people you’ve never met before’’). Widespread use of alcohol contributed to sexual risk taking (‘‘If you are drunk and high.you forget or just wouldn’t think of using protection’’) and multiple partners. Although this was widely acknowledged, almost no one expressed concern about these risks, stating that’s ‘‘just the way it is’’ in college. Suggested educational strategies Participants suggested that information about HPV be disseminated by university health services, and via text messaging and electronic mail. A large number believed that making educational sessions mandatory at freshman orientation would be the only way to get men to attend. They emphasized that men do not perceive HPV as a personal threat and therefore that information would be ignored unless susceptibility was emphasized (‘‘men need to know how it could impact them before they will listen’’). Discussion Understanding men’s knowledge about HPV and their receptivity to vaccination or other means of reducing HPV-
J.D. Allen et al. / Journal of Adolescent Health 45 (2009) 535–537
associated risk is important; declines in disease may only occur if there is reduction of infection among individuals of both genders [10]. Our results underscore the need for information about HPV transmission and potential consequences of HPV infection for men. Educational efforts directed at a male audience may be more effective if they stress HPV as causing genital warts, as well as anogenital and oral cancers. Concerns about the safety and efficacy of the vaccine will also need to be addressed if the vaccine is approved for use in men, as this has been strongly associated with vaccine intentions. Identifying trusted and credible sources of information, as well as developing messages that directly address vaccine-associated fears, are essential. Other areas for intervention might include building social norms that support safe sexual relationships, addressing excessive alcohol consumption, and increased availability of condoms and health information.
Acknowledgments The authors thank Samuel Clark, Dana Mars, Kristin Ferguson, and Erin Breen for their thoughtful contributions to this study.
537
References [1] Joseph D, Miller J, Wu X, et al. Understanding the burden of HPV associated anal cancers in the US. Cancer 2008;113:2892–900. [2] Hernandez B, Barnholtz-Sloan J, German Rea. Burden of invasive squamous cell carcinomoa of the penis in the US, 1988–2003. Cancer 2008;113:2883–91. [3] Dunne E, Nielson CM, Stone KM, et al. Prevalence of HPV infection among men: A systematic review of the literature. J Infect Dis 2006; 194:104–57. [4] Hu D, Goldie S. The economic burden of noncervical human papillomavirus disease in the United States. Am J Obstet Gynecol 2008; 198:500–7. [5] Chan P, Luk ACS, Luk TNM, et al. Distribution of human papillomavirus types in anogenital warts of men. J Clin Virol 2009;44:111–4. [6] Centers for Disease Control and Prevention. Fact Sheet for HPV Infection [Online]. 2006. Available at: http://www.cdc.gov/std/HPVFactHPV.htm. Accessed October 25, 2006. [7] Guiliano A. Human papillomavirus vaccination in males. Gynecol Oncol 2007;107:S24–6. [8] Ferris DG, Waller JL, Owen A, et al. Midadult women’s attitudes about receiving the prophylactic human papillomavirus vaccine. J Low Genit Tract Dis 2007;11:166–72. [9] Gerend M, Barley J. Human papillomavirus vaccine acceptability among young adult men. Sex Transm Dis 2009;36:58–62. [10] Guiliano A, Salmon D. The case for a gender-neutral (universal) human papillomavirus vaccination policy in the US: Point. Cancer Epidemiol Biomarkers Prev 2008;17:809.
Adolescent health brief
College Men’s Knowledge, Attitudes, and Beliefs about the Human Papillomavirus Infection and Vaccine Jennifer D. Allen, Sc.D., M.P.H., R.N.a,b,*, Heidi Collins Fantasia, Ph.D., R.N., W.H.N.P.-B.C.a, Holly Fontenot, M.S., R.N., W.H.N.P.-B.C., S.A.N.E.a, Stephen Flaherty, M.P.H.b, and Jeans Santanaa a William Connell School of Nursing, Boston College, Chestnut Hill, Massachusetts Center for Community-Based Research, Dana-Farber Cancer Institute, Boston, Massachusetts Manuscript received January 3, 2009; manuscript accepted May 28, 2009
b
See Editorial p. 427 Abstract
Men enrolled in an urban university participated in focus groups (k ¼ 6; n ¼ 45) to explore knowledge about human papillomavirus and attitudes toward prophylactic vaccine. Results suggest that regardless of whether vaccines become available to men, educational efforts should include them, as men tend to have many misconceptions and do not perceive themselves to be vulnerable. Ó 2009 Society for Adolescent Medicine. All rights reserved.
Keywords:
Human papillomavirus; HPV; College health; Men’s health
Human papillomavirus (HPV) is the most common sexually transmitted infection (STI) in the United States (U.S.). HPV is now recognized as a causative factor in cervical cancer in women and male genital disease. Oncogenic HPV types are associated with 93% of anal cancers [1] and 40% of penile cancers [2]. Among sexually active men 18–40 years of age, the prevalence of anogenital HPV may be as high as 72% [3]. Nononcogenic HPV types are believed responsible for 90% of genital warts and are associated with substantial morbidity, costing more than $400 million in the U.S. in 2003 [4]. Data have shown that men experience genital warts in longer duration than women [5]. Prophylactic vaccines are now approved for use among females in the U.S. [6]. Vaccine is licensed for male use in Mexico and Australia, and it is anticipated that it will soon become available to men in the U.S. [7]. The viral strains covered in both existing vaccines (types 16, 18) could drastically reduce the occurrence of anogenital warts in men, whereas the quadrivalent vaccine, which additionally covers types 6,11, could prevent up to 90% of genital warts [4]. Few studies have examined men’s attitudes toward the HPV vaccine since it was licensed for use in the U.S. [8,9].
The purpose of this study was to gain a better understanding of men’s knowledge and attitudes toward the HPV vaccine, to inform the development of effective population-based intervention strategies.
*Address correspondence to: Jennifer D. Allen, Sc.D., M.P.H., R.N., William Connell School of Nursing, Boston College, 140 Commonwealth Avenue, Boston, MA 02167. E-mail address: [email protected]
Knowledge and awareness
Methods Six focus groups with students 18–22 years of age (n ¼ 45) were conducted at a large private university in the Northeast. Students were recruited through campus advertisements. A male moderator facilitated using a semistructured guide (Table 1). Discussions were audiotaped and transcribed verbatim, and initial coding categories were developed. Open codes were collapsed into higher-order categories that reflected the predominant emergent themes. Data were collected until the point of saturation. Study protocols and procedures were approved by the University Institutional Review Board. Results Demographic data on participants are presented in Table 2. Dominant themes are presented below.
There was a high level of recognition of HPV as a STI. Men recognized that infection was more common among those
1054-139X/09/$ – see front matter Ó 2009 Society for Adolescent Medicine. All rights reserved. doi:10.1016/j.jadohealth.2009.05.014
J.D. Allen et al. / Journal of Adolescent Health 45 (2009) 535–537
536 Table 1 Question guide for focus groups Topic area
Sample questions
Health practices and concerns
What types of health issues do you think concern college men? What do you do to take care of your health? (probes: diet, physical activity, smoking, sexual health)
Knowledge and awareness of HPV
What do you know about sexually transmitted infections? Have you ever heard of HPV? If yes, what comes to your mind when you think of HPV? What do you know about HPV (probes: transmission, health consequences, symptoms, diagnosis, treatment)? How did you first hear about HPV
Knowledge and awareness of the HPV vaccine
Have you ever heard of a vaccine to prevent HPV? If yes, what have you heard? (probes: What does it do? Who is it for?) How did you first hear about the vaccine?
Vaccine acceptance- self and others
If the vaccine were available to you, would you choose to get it? Why or why not? Would you recommend the vaccine to your female friend(s), sister or (female) your significant other?
Suggested intervention strategies
Would college men be interested in learning more about HPV? What specifically do you think they would want to know? How would this information best be communicated?
with multiple sexual partners (‘‘guys who jump around’’) and those who do not use condoms (‘‘you gotta always wrap it up’’). Many recognized the connection with cervical cancer, but none associated HPV with anal, penile, or oropharyngeal cancer. Participants were aware that HPV was a common virus with no cure, but few understood the consequences of different viral strains or that the virus could be transmitted without symptoms. Most were incorrect in their descriptions of symptoms of infection (‘‘weird discharges and burning’’) and incorrectly believed diagnosis was made by ‘‘blood or urine.’’ None could name any form of treatment for genital warts. Low perceived susceptibility and severity Many did not know that men as well as women were susceptible to HPV or did not feel that HPV was a severe infection (‘‘I think it’s more of a joke’’). The majority acknowledged that infection could be serious for women, and referred to HPV as a ‘‘woman’s disease.’’ Those who knew about the link with cervical cancer did not feel that either the cancer or the infection were severe (‘‘you don’t hear a lot of death associated with HPV’’). Some cited condoms as protective measure but did not realize that condoms are only partially protective.
Table 2 Sample characteristics (n ¼ 45)
Race/ethnicity Caucasian/white African-American/black Hispanic/Latino Asian Other Year in school Freshman Sophomore Junior Senior Currently sexually active Yes No Missing
n
%
23 11 5 3 3
51 24 11 7 7
6 4 14 21
13 9 31 47
32 12 1
71 27 2
Uncertainty about the vaccine Many knew that a vaccine is available for women for prevention of cervical cancer. When asked about receiving the vaccine if it became available to men, apprehension was voiced about cost, accessibility, safety, and side effects. Although unsure for themselves, participants believed that women in general would benefit (‘‘better safe than sorry’’). However, reservations were expressed (‘‘there’s been so many things that women have taken that have supposed to help them which have ended up being negative for them’’). Contextual factors and risk ‘‘Hooking up’’ was a strong and pervasive theme. Men expressed that it was ‘‘safe’’ to have sex with students at their school, but individuals not enrolled at the school or casual acquaintances were seen as more risky (‘‘I feel like you’re a little safer [with class mates] than with people you’ve never met before’’). Widespread use of alcohol contributed to sexual risk taking (‘‘If you are drunk and high.you forget or just wouldn’t think of using protection’’) and multiple partners. Although this was widely acknowledged, almost no one expressed concern about these risks, stating that’s ‘‘just the way it is’’ in college. Suggested educational strategies Participants suggested that information about HPV be disseminated by university health services, and via text messaging and electronic mail. A large number believed that making educational sessions mandatory at freshman orientation would be the only way to get men to attend. They emphasized that men do not perceive HPV as a personal threat and therefore that information would be ignored unless susceptibility was emphasized (‘‘men need to know how it could impact them before they will listen’’). Discussion Understanding men’s knowledge about HPV and their receptivity to vaccination or other means of reducing HPV-
J.D. Allen et al. / Journal of Adolescent Health 45 (2009) 535–537
associated risk is important; declines in disease may only occur if there is reduction of infection among individuals of both genders [10]. Our results underscore the need for information about HPV transmission and potential consequences of HPV infection for men. Educational efforts directed at a male audience may be more effective if they stress HPV as causing genital warts, as well as anogenital and oral cancers. Concerns about the safety and efficacy of the vaccine will also need to be addressed if the vaccine is approved for use in men, as this has been strongly associated with vaccine intentions. Identifying trusted and credible sources of information, as well as developing messages that directly address vaccine-associated fears, are essential. Other areas for intervention might include building social norms that support safe sexual relationships, addressing excessive alcohol consumption, and increased availability of condoms and health information.
Acknowledgments The authors thank Samuel Clark, Dana Mars, Kristin Ferguson, and Erin Breen for their thoughtful contributions to this study.
537
References [1] Joseph D, Miller J, Wu X, et al. Understanding the burden of HPV associated anal cancers in the US. Cancer 2008;113:2892–900. [2] Hernandez B, Barnholtz-Sloan J, German Rea. Burden of invasive squamous cell carcinomoa of the penis in the US, 1988–2003. Cancer 2008;113:2883–91. [3] Dunne E, Nielson CM, Stone KM, et al. Prevalence of HPV infection among men: A systematic review of the literature. J Infect Dis 2006; 194:104–57. [4] Hu D, Goldie S. The economic burden of noncervical human papillomavirus disease in the United States. Am J Obstet Gynecol 2008; 198:500–7. [5] Chan P, Luk ACS, Luk TNM, et al. Distribution of human papillomavirus types in anogenital warts of men. J Clin Virol 2009;44:111–4. [6] Centers for Disease Control and Prevention. Fact Sheet for HPV Infection [Online]. 2006. Available at: http://www.cdc.gov/std/HPVFactHPV.htm. Accessed October 25, 2006. [7] Guiliano A. Human papillomavirus vaccination in males. Gynecol Oncol 2007;107:S24–6. [8] Ferris DG, Waller JL, Owen A, et al. Midadult women’s attitudes about receiving the prophylactic human papillomavirus vaccine. J Low Genit Tract Dis 2007;11:166–72. [9] Gerend M, Barley J. Human papillomavirus vaccine acceptability among young adult men. Sex Transm Dis 2009;36:58–62. [10] Guiliano A, Salmon D. The case for a gender-neutral (universal) human papillomavirus vaccination policy in the US: Point. Cancer Epidemiol Biomarkers Prev 2008;17:809.