SHORT REPORT
Awareness of human papillomavirus among women
attending a well woman clinic
J Waller, K McCaffery, S Forrest, A Szarewski, L Cadman, J Wardle
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Sex Transm Infect 2003;79:320-322
Objectives: To assess the level and accuracy of public
understanding of human papillomavirus (HPV) in the
United Kingdom.
Methods: Women attending a well woman clinic were
asked to complete a questionnaire assessing HPV
awareness and specific knowledge about the virus.
Results: Questionnaires were completed by 1032
women, of whom 30% had heard of HPV. Older women,
non-smokers, and those with a history of candida, genital
warts, or an abnormal smear result were more likely to
have heard of HPV. Even among those who had heard of
HPV, knowledge was generally poor, and fewer than half
were aware of the link with cervical cancer. There was
also confusion about whether condoms or oral contraceptives could protect against HPV infection.
Conclusions: In this relatively well educated sample,
awareness and knowledge of HPV were poor. Public education is urgently needed so that women participating in
cervical cancer screening are fully informed about the
meaning of their results, especially if HPV testing is soon to
be introduced.
H
uman papillomavirus (HPV) is widely acknowledged to
be the most prevalent sexually transmitted infection
(STI) in the United States1
and elsewhere. High risk
types of HPV are a necessary though not sufficient cause of the
vast majority of cervical cancers.2
In the United States, HPV
testing is recommended for the triage of women with borderline smear results.3
A similar system is being considered in the
United Kingdom, and HPV testing in primary screening has
also been suggested.4
Studies in the United States have found low awareness of
HPV among women in university and healthcare settings.5-9
In
the United Kingdom, 70% of female university employees surveyed had never heard of the virus10
and in a representative
population sample, fewer than 1% recalled HPV as a risk factor for cervical cancer (unpublished data).
It is critical that women participating in cervical screening
are aware of HPV and its causal role in cervical intraepithelial
neoplasia (CIN) and cancer. Information about HPV has been
found to cause confusion among women with no prior knowledge of the virus or its link with cervical cancer11
and smear
results which mention "wart virus" are poorly understood.12
We assessed HPV knowledge among women attending a
well woman clinic to gain an understanding of the level and
accuracy of public awareness.
METHODS
Participants
Participants were women attending the Margaret Pyke
Centre, an NHS well woman clinic in central London. Speaking English was the only inclusion criterion. Participants'
reasons for attending the centre are shown in table 1 and are
broadly representative of the clinic as a whole.
Measures
Knowledge of HPV was measured using a series of questions
similar to those used in other studies.6-10
Women who reported
having heard of HPV were asked how they had heard about it.
They also responded to six statements about HPV with "true,"
"false," or "don't know" (see table 2).
Demographic characteristics and STI and cervical screening
history were also assessed with simple questions.
Procedure
Women attending the centre over 15 months between 2000
and 2002 were asked to complete a survey about cervical
screening and HPV self sampling. Selected clinic sessions were
targeted each week to ensure that women attending for
different reasons were included. Those attending for smear
tests were invited to participate in a trial of HPV self testing,
the results of which will be presented elsewhere. The study
was approved by the University College London Hospitals local
research ethics committee.
RESULTS
Characteristics of the sample
The response rate was high, with approximately 80% of
women who were asked agreeing to complete a questionnaire.
Those who declined mostly did so because of time constraints.
Of the 1045 women completing the questionnaire, 13 did not
respond to the question about having heard of HPV and are
excluded from all analyses, leaving a sample size of 1032. Participants were representative of the clinic population being
predominantly young (mean age 30.2 (SD 7.7)), white, well
educated, and in full time employment (see table 1). Equal
numbers of women were married/cohabiting (47%) and single
(47%). Most reported having had between one and three
sexual partners in the past year and 27% reported a previous
diagnosis of an STI.
HPV knowledge
About 30% of women (316/1032) had heard of HPV. There
were significant, but generally small associations with demographic characteristics (see table 1). Awareness of HPV was
higher in older (47%) than younger women (25%). Women
reporting a history of candida or genital warts had higher
awareness of HPV, as did those who reported ever having an
abnormal smear result. Not surprisingly, knowing someone
who had had HPV was associated with greater awareness.
Awareness was lower among smokers (22%) than non-smokers (35%). When the significant predictors were entered
into a logistic regression model (see table 1), all remained significant independent predictors of awareness of HPV except
experience of an abnormal smear result.
Even among women who had heard of HPV (n=316),
knowledge was poor (see table 2). They generally knew that
HPV was sexually transmitted and could be carried by men,
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but fewer than half knew that it is the main cause of cervical
cancer, and only a third knew that genital warts do not cause
cervical cancer. The majority believed condoms to be
protective and, worryingly, only half knew that the contraceptive pill does not protect against HPV infection. The most
common sources of information were the media or a general
practitioner. Women who had heard about it from an "other"
source cited a wide variety including pamphlets, sexual health
classes, through having had HPV in the past, or having a
medical background.
DISCUSSION
This is the first study to evaluate HPV knowledge among
women in a primary healthcare setting in the United
Kingdom. In this predominantly young and sexually active
population, only 30% reported awareness of HPV, and knowledge was generally poor even among those who had heard of
it, consistent with the findings of previous US and UK
studies.5-9
Given that the sample was highly educated, and
there was some evidence of a trend towards poorer knowledge
among less educated women, it is likely that knowledge in the
general population is even lower. However, the age effect
would be in the opposite direction, as the sample was skewed
towards younger women who had lower awareness.
Awareness of HPV was associated with experience of
candida, genital warts, or an abnormal smear, indicating that
attending for treatment for these might expose women to
information about HPV. Knowing someone who has had HPV
was another predictor of awareness, although women
generally cited the media or their general practitioner as
sources of knowledge.
Awareness was lower among smokers, which is of concern
as smoking increases the risk of cervical abnormalities and
cancer among women with HPV infection. Raising awareness
of the virus and the role of cigarette smoking in viral persistence and CIN progression among smokers should be a priority.
Women's uncertainty about whether the pill protects
against HPV partly reflects their lack of knowledge about the
sexually transmitted nature of the virus. Of those who knew
Table 1 Characteristics of the whole sample (n=1032) and women who were aware (n=316) and unaware (n=716) of
HPV, with 2
tests for between group differences and odds ratios for significant predictors
Whole sample
(n=1032)
Women aware of
HPV (n=316)
Women unaware
of HPV (n=716)
Difference between
groups 2
[df] (p)
Odds ratio of having
hear of HPV [95% CI]
% No % No % No
Age (years)
16-25 30.0 310 24.7 78 32.4 232 1.00
26-35 47.9 494 47.2 149 48.2 345 13.3 [3] (0.004) 1.19 [0.82 to 1.74]
36-45 15.6 161 17.7 56 14.7 105 1.20 [0.72 to 1.98]
46 and over 5.5 57 8.5 27 4.2 30 2.40 [1.23 to 4.68]
Age of leaving full time education
16 and under 8.1 84 6.6 21 8.8 63
17-18 15.7 162 13.9 44 16.5 118 NS
19 and over 74.0 764 78.2 247 72.2 517
Still in full time education and under 19 0.6 6 0 0 0.8 6
Ethnicity
White 83.7 864 83.9 265 83.7 599
Black 3.4 35 2.8 9 3.6 26 NS
Asian 4.5 46 4.1 13 4.6 33
Other 5.5 57 4.7 15 5.9 42
Housing tenure
Rent from local authority 5.7 59 4.4 14 6.3 45
Rent from private landlord 47.4 489 49.4 156 46.5 333 NS
Own/buying home 35.0 361 36.7 116 34.2 245
Live with parents 4.5 46 2.8 9 5.2 37
Other 6.2 64 5.7 18 6.4 46
Marital status
Married/living with partner 47.1 486 48.1 152 46.6 334
Single 47.4 489 46.2 146 47.9 343 NS
Separated/divorced/widowed 4.4 45 4.1 13 4.5 32
Work status
Working full time 73.2 755 75.3 238 72.2 517
Working part time 9.2 95 7.6 24 9.9 71 NS
Not working at present 6.4 66 6.6 21 6.3 45
Student 10.0 103 9.5 30 10.2 73
Do you smoke cigarettes? (yes) 34.3 354 25.0 79 38.4 275 17.0 [1] (<0.0001) 0.52 [0.36 to 0.74]
Number of sexual partners in the last year
None 4.1 42 3.5 11 4.3 31
1 65.8 679 65.8 208 65.8 471 NS
2-3 22.4 231 22.5 71 22.3 160
4 or more 6.2 64 6.6 21 6.0 43
STI history
Candida (thrush) 51.4 530 59.5 188 47.8 342 15.3 [1] (<0.0001) 1.47 [1.06 to 2.03]
Genital warts 10.1 104 18.0 57 6.6 47 33.8 [1] (<0.0001) 2.37 [1.41 to 3.56]
Other STI* 20.5 212 23.7 75 19.1 137 NS
Previous abnormal smear result (yes) 26.4 272 35.1 111 22.5 161 17.9 [1] (<0.0001) 1.28 [0.88 to 1.85]
Know someone who has had HPV (yes) 8.7 90 23.7 75 2.1 15 114.2 [1] (<0.0001) 11.80 [6.47 to 21.54]
Reason for attending clinic
Smear test 32.7 337 33.2 105 32.4 232
Smear test and contraceptive advice 11.5 119 15.2 48 9.9 71 NS
Contraceptive advice 46.8 483 45.6 144 47.3 339
Colposcopy 2.8 29 2.2 7 3.1 221
*Herpes simplex, Trichomonas vaginalis, chlamydia, gonorrhoea, anaerobic vaginosis, pelvic inflammatory disease, non-specific urethritis.
HPV awareness 321
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that HPV is sexually transmitted, 70% were aware that the pill
is not protective, compared with only 32% of those who did
not know or were not sure that HPV is an STI. It is also possible that the protective role of the pill in other gynaecological
cancers might have influenced women's beliefs about its
impact on HPV risk.
The majority of women believed that condoms are
protective against HPV, although the evidence for this is
unclear. It seems likely that condoms provide some
protection,13
but the message about condom use will need to
be clarified so that women can be given consistent information.
Caution must be exercised when drawing conclusions
beyond our sample, as it was not representative of the UK
population, being younger, better educated, and more predominantly white. However, low HPV awareness was consistent with other studies, which lends credence to this finding.
Public education about HPV is essential, in order that
women participating in cervical screening understand the
possible results of the smear test, particularly if HPV testing is
introduced. Clear and consistent messages about HPV
transmission, cancer risk, and protection must be developed in
order that women are fully informed when they participate in
cervical screening.
ACKNOWLEDGEMENTS
This study was funded by Cancer Research UK. We would also like to
thank the staff and patients at the Margaret Pyke Centre for their time
and cooperation in the study.
CONTRIBUTORS
AS, JaW, and LC conceived the study and obtained funding; KM and
SF designed the measures and conducted the fieldwork; JoW contributed to the field work, carried out the data analysis and wrote the first
draft of the text; all authors commented on drafts and contributed to
the final manuscript.
. . . . . . . . . . . . . . . . . . . . .
Authors' affiliations
J Waller, K McCaffery, S Forrest, J Wardle, Cancer Research UK
Health Behaviour Unit, Department of Epidemiology and Public Health,
UCL, 2-16 Torrington Place, London WC1E 6BT, UK
A Szarewski, L Cadman, Department of Mathematics, Statistics and
Epidemiology, Cancer Research UK, 61 Lincoln's Inn Fields, London
WC2A 3PX, UK
K McCaffery, Screening and Test Evaluation Program, School of Public
Health, University of Sydney, NSW 2006, Australia
Correspondence to: Jo Waller, CRUK Health Behaviour Unit, Department
of Epidemiology & Public Health, UCL, 2-16 Torrington Place, London
WC1E 6BT, UK; j.waller@public-health.ucl.ac.uk
Accepted for publication 13 February 2003
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Table 2 HPV knowledge among those who had
heard of it (n=316 out of total sample of 1032)
% No
How did you hear about it?
GP 18.7 59
Friend or family member 13.9 44
Internet 2.2 7
TV/magazine/newspaper 38.3 121
Other 23.4 74
HPV sexually transmitted (true)
True 64.9 205
False 7.3 23
Not sure 25.3 80
HPV main cause of cervical cancer (true)
True 40.2 127
False 15.2 48
Not sure 42.7 135
Men can carry HPV (true)
True 63.9 202
False 3.8 12
Not sure 29.7 94
Genital warts cause cervical cancer (false)
True 24.1 76
False 34.2 108
Not sure 38.9 123
The pill protects against HPV (false)
True 7.0 22
False 55.1 174
Not sure 34.8 120
Condoms protect against HPV (uncertain)
True 66.5 210
False 9.5 30
Not sure 20.6 65
322 Waller, McCaffery, Forrest, et al
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