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Does viewing an educational documentary about HPV disease and vaccination on
a college campus in rural Northwest PA improve the knowledge level of HPV
disease and vaccine among attendees of the program?
Dianne Luc
Clarion and Edinboro Universities
Spring 2018
Colleen R. Bessetti-Barrett, DNP, CRNP, FNP-BC – Co-author, Committee Chair
Jill Rodgers, DNP, CRNP, FNP-BC – Program Advisor, Committee Member
Karen Wiggers, RN, BSN – Committee Member
Dedication
My DNP project is dedicated to my family whose unwavering support and
understanding enabled me to realize my dream. To my husband, for all the sleepless
nights taking care of our children, listening to my frustrations and putting up with my
petulance. To my children Ethan, Anthony, and Angelina Rose who give me strength
and purpose. May you look back and understand the moments in your life when I was
not there for your karate tournaments and playdates. And may you be encouraged and
be proud of me. To my mom and dad, my number one cheerleaders, thank you for
always believing in me and for pushing me to keep reaching for the stars. Your
optimism, encouragement, and love have pushed me though many difficult and
challenging moments. You both have been the shining light that guided me not only
through my studies but throughout my life. To my siblings, whom I call on last minute
for miscellaneous things. Special gratitude from the bottom of my heart to my sister
Joyce for your uplifting spirit and all your help. Thank you for always being there when I
need you. To my parents-in-law and my sister-in-law, Jodie, for babysitting and making
sure I am healthy. As I reflect on my journey, I feel blessed that I have all of you in my
life. Thank you for walking this journey with me.
ii
Acknowledgements
I would like to acknowledge and express my sincere gratitude to my DNP
committee for their expertise, support, and guidance. Your advice and knowledge were
vital to the successful completion of my project. I would like to thank all the professors
who have guided me along the way. To Dr. Bessetti-Barrett, for your patience and
understanding in every situation and for your guidance and sharing your immense
knowledge with me. To Dr. Rodgers, for being a great professor and for helping me
grow. To Karen, for providing insight and resources that helped assist with the study.
And finally, to Edinboro University, for providing the conference room and the
environment for me to implement my DNP project.
Colleen R. Bessetti-Barrett, DNP, CRNP, FNP-BC – Co-author, Committee Chair
Jill Rodgers, DNP, CRNP, FNP-BC – Program advisor, Committee Member
Karen Wiggers, RN, BSN – Committee Member
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Table of Contents
Dedication.........................................................................................................................ii
Acknowledgements……………………………………………………………………….….…iii
Table of Contents.............................................................................................................iv
Tables and Figures..........................................................................................................vi
Abstract.............................................................................................................................x
Background.......................................................................................................................1
HPV Vaccine Reccomendations.......................................................................................2
HPV Vaccine Statistics……………………………………………………………………...….3
Economic Burden…………………………………………………………………………....….4
Barriers………………………………………………………………………………………......5
Strategies……………………………………………………………………………………...…6
HPV Knowledge, Perceptions and Vaccination Rate Among College Students………....6
HPV Initiatives in Pennsylvania…………………………………………………………….….8
Statement of the Problem…………………………………………………………………….10
Synthesis of Evidence…………………………………………………………………………10
Methods..........................................................................................................................12
Setting.............................................................................................................................12
Study Design……………………………………………………………………...……………12
Participant Recruitment…………………………………………………………………….....12
Inclusion and Exclusion Criteria......................................................................................13
Participant Demographic…………………………………………………………………...…13
iv
Insturment......................................................................................................................14
Intervention………………………………………………………………………………….….14
Data Analysis……………………………………………………………………………….….14
Discussion………………………………………………………………………………………15
Conclusion…………………………………………………………………………………...…16
References……………………………………………………………………………………..17
v
Tables and Figures
Table 1. Test Scores Before and After Education Video
Student
Before
After
1
4/8
8/8
2
8/8
8/8
3
7/8
8/8
4
8/8
8/8
5
7/8
8/8
6
7/8
8/8
7
5/8
7/8
8
6/8
7/8
9
3/8
7/8
10
6/8
8/8
11
7/8
7/8
12
5/8
7/8
13
5/8
8/8
14
5/8
8/8
15
5/8
8/8
16
6/8
6/8
17
7/8
7/8
18
7/8
7/8
19
7/8
7/8
20
7/8
8/8
21
8/8
8/8
22
6/8
6/8
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Table 2. Questions and the percentage of improvement post educational session
Question
1. HPV is a common sexually transmitted infection.
% Improvement
Post Training
9
2. HPV causes cervical cancer.
14
3. HPV does not cause cancers of the head or neck.
23
4. Men can become infected with the HPV virus.
9
5. Only women can become infected with the HPV virus.
14
6. Most people who contract HPV from a partner will not have any symptoms of
HPV disease.
7. There is a vaccine available to help prevent certain types of HPV infections.
23
8. The HPV virus causes genital warts.
27
vii
9
Figure 1. Paired T-Test and CI: correct pre, correct post
Descriptive Statistics
Sample
N
Mean
StDev
SE Mean
correct pre
22
6.182
1.332
0.284
correct post
22
7.455
0.671
0.143
Estimation for Paired Difference
Mean
StDev
SE Mean
-1.273
1.386
0.296
95% CI for
μ_difference
(-1.887, -0.658)
µ_difference: mean of (correct pre - correct post)
Test
Null hypothesis
H₀: μ_difference = 0
Alternative hypothesis
H₁: μ_difference ≠ 0
T-Value
P-Value
-4.31
0.000313
Histogram of Differences
(with Ho and 95% t-confidence interval for the mean)
10
8
Frequency
6
4
2
0
_
X
Ho
-4
-3
-2
Differences
viii
-1
0
Figure 2. Capability Comparison Analysis
Before/After Poisson Capability Comparison for incorrect pr vs incorrect po
Summary Report
Process Characterization
Reduction in Defects per Unit (DPU)
70%
DPU was reduced by 70% from 0.227 to 0.068.
Is the DPU at or below 0?
0.0
0.05
Before
After
22
8
176
40
22
8
176
12
Number of subgroups
Subgroup size
Total units tested
Total defects
0.1
> 0.5
Yes
Process Capability (Overall)
No
No test is performed when you set the maximum acceptable DPU to 0.
DPU
95% CI
Yield
Before
After
Change
0.227
(0.162, 0.309)
79.7%
0.068
(0.035, 0.119)
93.4%
-0.159
13.7%
Yield is the chance of producing a unit with no defects.
Observed DPU per Subgroup
Where are the data relative to the acceptable level?
Comments
0
Before: Average DPU = 0.227
Before: incorrect pr
Acceptable DPU: 0
After: incorrect po
• Before: The process DPU was greater than the maximum acceptable level
of 0.
• After: The process DPU is greater than the maximum acceptable level of 0.
• The chance of producing a unit with no defects improved from 79.7% to
93.4%.
After: Average DPU = 0.068
0.0
0.1
0.2
0.3
0.4
0.5
0.6
ix
Abstract
Human Papillomavirus (HPV) is the most common sexually transmitted infection
causing cervical, oropharyngeal cancers and genital warts. In the United States (U.S.), it
is estimated that one in four individuals are infected, with an additional 14 million new
cases of HPV infections occurring annually. HPV contributes to 17,600 cancers in
women and 9,300 cancers in men annually. HPV vaccine is the most effective way to
protect against HPV related cancers. However, there is a lag in HPV vaccination due to
barriers such as: health care providers hesitancy to promote the HPV vaccine, low
baseline knowledge of HPV and HPV vaccine, safety concerns, cost and system
barriers. Studies show that there is low overall knowledge of baseline HPV and HPV
vaccine among college students. The purpose of this study is to determine if an
educational video intervention increases baseline knowledge of HPV and HPV vaccine
in the attendees on a college campus in Northwestern Pennsylvania. To test this, a
study design consisting of an educational session that utilizes an HPV educational
video, followed by a brief question and answer session was developed. A questionnaire
is implemented pre- and post-intervention to analyze HPV knowledge in participants.
There were 22 participants who completed the study. Comparison analysis between the
pre- and post-knowledge assessments show statistically significant improvement of
results after viewing the educational documentary on HPV. The likelihood of getting a
perfect score on the assessment increased by 13.7%, equating to a 70 percent
reduction of incorrect answers from viewing the educational video.
x
Does viewing an educational documentary about HPV disease and vaccination
on a college campus in rural Northwest PA improve the knowledge level of HPV disease
and vaccine among attendees of the program?
Background
Human Papillomavirus (HPV) is a common virus that is associated with skin
warts, anogenital, oropharyngeal and cervical cancer (Centers for Disease Control and
Prevention [CDC], 2017). In the United States (U.S.) alone, an estimated 79 million
individuals are infected, with an additional 14 million new cases of HPV infections
occurring yearly. HPV contributes to 17,600 cancers in women and 9,300 cancers in
men annually (CDC, 2017). HPV vaccine is the most effective and safest protection
against HPV related cancers. Although there is an increase in HPV vaccination since
its introduction in 2006, it remains disproportionately low in comparison to other
adolescent vaccines. Four out of ten adolescent girls, and six out of ten adolescent
boys are unvaccinated against HPV, and are vulnerable to cancer (CDC, 2015).
HPV is transmitted through skin to skin contact, mostly through sexual activity
with an infected individual. There are over 120 HPV types that have been identified.
Forty of them are associated with cervical cancer. Low risk or non-oncogenic types
such as types 6 and 11 causes genital warts, and laryngeal papillomas. High risk or
oncogenic HPV types results in cervical, anogenital and oropharyngeal cancers. More
than 99% of cervical cancer is related to HPV; and type 16 and 19 accounts for about
70% of cervical cancers (Warren, 2009).
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In the U.S. about 11,000 women are diagnosed with cervical cancer, and about
4,400 of those women die annually (CDC, 2013). In men, oropharyngeal cancer is the
most common cancer cause by HPV. HPV causes 91% of anal cancers, 75 % of
vaginal cancers, 69 % of vulvar cancer, and 63 % of penile cancers (CDC, 2018).
About one in 100 sexually active adults in the U.S. has genital warts at any given time.
The highest rate of new HPV infections is between the ages of 15-24 years old (CDC,
2013).
The National Health and Nutrition Examination Survey (NHANES) 2011–2014,
provided some statistics regarding HPV among adults aged 18 to 59 years old. The
prevalence of oral HPV for adults during 2011 to 2014 was 7.3%, and high-risk HPV
was 4.0%. Data from 2013 to 2014 showed that prevalence of any and high-risk genital
HPV was 45.2% and 25.1% in men and 39.9% and 20.4% in women, respectively.
“Prevalence of any and high-risk oral HPV was overall lowest among non-Hispanic
Asian adults and was highest among non-Hispanic black adults. Prevalence of any and
high-risk oral HPV was higher in men than women except for high-risk HPV among
Asian adults. Prevalence of any and high-risk genital HPV was lower among nonHispanic Asian and higher among non-Hispanic black than both non-Hispanic white and
Hispanic men and women” (McQuillan, G., Kruszon-Moran, D., Markowitz, L.E., Unger,
E.R., & Paulose-Ram, R., 2017).
HPV Vaccine Recommendation
The CDC and Advisor Committee on Immunization Practices (ACIP) updated the
HPV vaccine recommendation in October of 2016. The new recommendation is for 11
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or 12-year-old boys and girls to receive two doses of HPV vaccine instead of three
doses for individuals starting the vaccination series before the age of 15 years old.
Vaccinations needs to be 6 to 12 months apart. Three doses of HPV vaccine are
recommended for individuals starting the vaccination series on or after the 15th
birthday, and for people with certain immunocompromising conditions (CDC, 2017).
ACIP recommends female vaccination at aged 13 through 26; and for males aged 13
through 21 for persons without adequate vaccination in the past. Immunocompromised
individuals, transgender adults, and males who are bisexual, transgender or who plan to
have sex with other men are recommended to get the three-series schedule: 0, 1-2
months, 6 months; and can be vaccinated until the age of 26. The vaccination series
can still be started at age 9 (CDC, 2016). This change was recommended by the CDC
and the ACIP after data showed that the antibody responses after two doses given at
least 6 months apart to 9-14 years old was as good or even better than the three doses
given to older adolescents and young adults, the age group in which efficacy was
demonstrated in clinical trials (CDC, 2017). Ideally, vaccination should be administered
prior to HPV exposure. Thus, it is recommended to vaccinate adolescents prior to their
first sexual encounter (CDC, 2016).
HPV Vaccine Statistics
HPV vaccine uptake is low when compared to other adolescent vaccines. In
2015 among males, coverage with ≥1 HPV vaccine dose was 49.8% and with ≥3 doses
was 28.1%. The females’ coverage with ≥1 dose was 62.8% and with ≥3 doses was
41.9%. This shows that there were less series completion compliance. In 2015, among
all adolescents (females and males combined), HPV vaccination coverage with ≥1 dose
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was 56.1% (95% CI = 54.9%–57.4%), with ≥2 doses was 45.4% (95% CI = 44.2%–
46.7%), and with ≥3 doses was 34.9% (95% CI = 33.7%–36.1%). Among all
adolescents, coverage with ≥1 HPV vaccine dose was 30.3 % points lower than
coverage with ≥1 Tdap dose and 25.2 % points lower than coverage with ≥1 MenACWY
dose (CDC, 2016; Reagan-Steiner,2016). Thus, HPV vaccine uptake is lagging
compared to other adolescent vaccines.
Pennsylvania (PA) is above the national vaccine coverage average with
coverage among males, coverage with ≥1 HPV vaccine dose was 55.9% and with ≥3
doses was 47.8%. The females coverage with ≥1 dose was 62.2% and with ≥3 doses
was 47.8% (CDC, 2016). However, HPV vaccine uptake remains low with low
compliance to complete the vaccination series. Therefore, strategies to
increase HPV uptake is vital in preventing HPV-related disease (CDC, 2016).
Economic Burden
HPV infections causes economic burden. An estimated $8.0 billion annual direct
medical cost is spent on prevention and treatment of HPV infections (Chesson et al.,
2012). Although genital warts and other low-grade types are medically benign, and can
resolve on its own, diagnosis of genital warts or an abnormal Pap smear is costly, and
results in emotional distress. Another study by Soper (2006) estimated that $3.4 billion
is spent annually on diagnosis and treatment of HPV infection and its associated
cervical diseases. About 90% of the estimated cost is due to preventative measures
such as treatment of precancerous lesions and routine Pap tests. The remaining 10%
is attributed to treatment of cervical cancer.
4
Most of the burden of HPV associated healthcare cost is seen in adolescents and
young adults. According to Sober (2006), the estimated lifetime total medical cost of
HPV infection for men and women aged 15–24 is $2.9 billion. Additionally, an annual
total direct medical cost for treatment of anogenital warts in all age groups for the year
2000 was $167.4 million. It is apparent that HPV related infection produces a significant
economic burden. HPV vaccine can help prevent HPV infections which will increase
quality of life, decrease health care cost significantly, therefore producing a healthier
population. Promotion of HPV vaccine and effective strategies to tackle the low uptake
of HPV vaccine disease is vital (CDC,2017).
Barriers
According to CDC, missed clinical opportunities is the most important reason for
the low HPV vaccine uptake. Many vaccine-eligible adolescents do not receive HPV
vaccines, while receiving at least one other vaccine. Other factors contributing to the
low utilization of HPV vaccinations include:
•
health care providers hesitancy to promote and vaccinate due to knowledge gap
•
lack of overall knowledge of HPV leading to misinformation
•
discomfort of practitioners regarding sexual behaviors
•
cost
•
safety and efficacy
System barriers such as lack of tools to remind practitioners, time constraints are
prominent contributing problems. (Holman et al., 2014). In the underserved
populations, limited knowledge about the vaccine is more pronounced, cultural
5
differences, insurance coverage and immigration status increased resistance to HPV
vaccination (Garcia, 2013). Barriers to vaccination in the college students noted were
side effects, costs, and lack of basic knowledge regarding HPV and HPV vaccination
(Burke et al., 2010).
Strategies
Strategies used to combat this public health threat includes effective education,
implementation of tools such as the AFIX approach recommended by the CDC,
reminder and recall systems, assessment and feedback, and other tools reminding
providers to check immunization history, as well as strong consistent recommendation
and promotion by providers for the HPV vaccine (CDC, 2018). Increase in collaboration
and communication within health care providers are also imperative. One of the
Healthy People’s objectives for 2020 is to increase HPV vaccine series among U.S.
female age 13-15 years old by 80 percent. Efforts that address system-level barriers to
vaccination will help to increase overall HPV vaccine uptake (Holdman et al., 2014).
Health care providers need to actively take on the responsibility and make HPV
vaccination a public health priority in order to save lives.
HPV knowledge, perception, and vaccination rate among college students
Knowledge of HPV and HPV vaccine in college students is low. A study by
Lambert (2001) evaluated knowledge in two groups of college students who were
subjected to HPV focused education that consisted of pre and post intervention
questionnaires three months apart. The results showed that the participants had low
overall knowledge regarding HPV disease. However, there was a statistically significant
improvement of HPV knowledge post interventions. Dillard and Spear (2010) assessed
6
knowledge of HPV and perceived barriers to being vaccinated against HPV virus at
Penn State University and found that although awareness of HPV and HPV virus was
high; only 65% had knowledge of HPV related facts. The lack of knowledge about HPV
is a common barrier to HPV vaccine uptake (Sheaves, 2016)
The perception of low risk for HPV and institutional barriers were cited as the
most common reasons for parent’s refusal to vaccinate their children (Navalpakam et
al., 2016). A literature review regarding attitudes and sexual behavior among women
college students in the U.S. showed that the women perceived HPV infection as a
serious health risk and had a positive outlook on HPV vaccine; but many do not
perceive themselves at risk (Ratanasiripong, 2012). This is also echoed by another
study at Oakland University of female college students with the majority of the
participants perceived that HPV is life threatening and prevents cervical cancer;
however, about 50% of the participants did not believe they were at risk (Navalpakam et
al., 2016). Effective unbiased education regarding HPV and HPV vaccine to increase
knowledge with the emphasis of risk to the individual is an important aspect of HPV
focused education.
A study assessing HPV vaccination and its correlation among culturally diverse
18-26-year-old community college women in Los Angeles, looked at what proportion of
the respondents have started the HPV vaccine, and what proportion have completed
the vaccine series. Additionally, it looked at what variables such as demographics,
psychosocial, and health care related issues are linked to vaccines initiation for the
respondents. The results show that those who started the vaccine series were younger,
more often had a health-related academic major, believed that HPV vaccine was safer,
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perceived HPV severity lower, and perceived higher social approval for the vaccine than
those who were unvaccinated. All the respondent who initiated the vaccine received
recommendation for the vaccine from their health care provider (Marchand et al., 2012).
In addition, a study of a southeastern university showed that out of the 875
survey respondents, only 78.6% indicated that they would get vaccinated. Out of the
respondents who self-identified as not yet sexually active; only 60.7% plan to get
vaccinated. Respondents concern about vaccine safety, side-effects, cost and lack of
knowledge were common barriers noted (Burke et al., 2010). Thus, increasing
knowledge regarding HPV and HPV vaccine through focused educational efforts is
needed to improve HPV knowledge, and decrease HPV related infections.
HPV initiatives in Pennsylvania
In an effort to increase HPV awareness and promote HPV vaccination, the PA
Department of Health (DOH) has created a powerful documentary called “Someone You
Love: The HPV epidemic”. The video follows five young women with HPV and shows
how HPV infection has affected their lives. The PA DOH has utilized healthcare
organizations to use the video as a tool to increase HPV knowledge and HPV
vaccination uptake. In 2016, the PA DOH had set up a program called PROTECT
Against HPV: A collaboration for community and provider outreach under Crawford
Health Improvement Coalition (CHIC) to utilize the video as a tool through a schoolbased campaign, a healthcare campaign and a community campaign (Crawford County
Health Improvement Coalition, 2016).
A post survey is completed following the showing of the video. According to the
data collected and presented on June 13, 2017, “Someone you love: The HPV
8
epidemic” video was shown in six locations in PA: Dietrich Theater Trunkhannock
(N=42), Meadville (N=34), Temple University in Harrisburg (N=13), Titusville (N=8),
Mechanicsburg (N=1), and online (N=1). The total sample size was N=99 participants.
Most of the participants heard about the program through others: email, phone blast,
school (36.4%), friends (21.8%), flyer (17.3%), Newspaper (8.2%), health care provider
(7.2%), social media (6%) and movie ad (4%). Only N=93 of the participant responded
to the questionnaire.
The participants average age is approximately 38.7 years old, consisting of
parent/guardian (28.5%), community member (21.5%), health care provider (17.7%),
student (15.1%), grandparent (9.1%) and educator (8.1%), with total responders of
N=98. There was a significant increase of support for HPV vaccination post viewing.
“Very supportive” of HPV vaccination increased from 45.9% to 85.9%, “supportive” from
29.6% to 11.15%, and “still undecided” decreased from 5% to 3%. Prior to the viewing,
9.2% had no knowledge of HPV and HPV vaccine. No individuals in the study were “not
supportive” pre and post viewing. The total respondents pre-viewing was N=98 and
post-viewing was N=99. Post-viewing, 58.6% chose “I will encourage those I know to
get the HPV vaccination”, 31.5% chose “I will get myself/my child all 3 HPV shots”, and
9.9% chose “I will talk to my healthcare provider about getting the HPV vaccination”.
The last question was not mutually exclusive, so respondents can pick one or more
answer to the question. Data from the effort show an increase in support for HPV
vaccination post-viewing. Knowledge however, was not assessed specifically postviewing. Strategies incorporating focused educational videos have proven to be an
effective tool to increase knowledge (Krawczyk, 2011).
9
Statement of the problem
HPV vaccine uptake has been lagging compared to other adolescent vaccines.
Studies show that knowledge of HPV and HPV vaccine in college students are low.
This is concerning since vaccination is the best prevention measure against HPV
infections. In Pennsylvania, only 48.2 percent of females between 13 and 17 years old
and 26 percent of males received all three shots in 2014. While in the Pittsburgh region,
27 percent of girls and 21.8 percent of boys ages 14-17 were fully vaccinated in 2014
(Rosenblatt, 2016). The objective of this scholarly study is to add to the literature by
examining whether a focused educational video on HPV and the HPV vaccine such as
the video, “Someone You Love: The HPV Epidemic”, increases baseline knowledge
among the participants. A secondary goal is to aid and contribute to the PA DOH’s data
collection in an effort to spread awareness though the promotion on the educational
video.
Synthesis of evidence
A search of literature was performed to answer the question: Does viewing an
educational documentary about HPV disease and vaccination on a college campus in
rural Northwest PA improve the knowledge level of HPV disease and vaccine among
attendees of the program? The search was performed using Cumulative Index of
Nursing and Allied Health Literature (CINAHL), Medline, PubMed and EBSCO
databases. The search terms that were used were: “HPV vaccine”, AND “increase
knowledge”, and “educational video”. Limits placed included: English language, items
with abstracts, full text articles, time frame range from 2001-2017, geography to USA.
Inclusion criteria included articles related to increasing HPV vaccination, educational
10
videos, increase knowledge. Exclusion criteria included any article that did not pertain
to increasing knowledge with the use of educational or training video, and any studies
done outside U.S.
The search engines yielded 1452 results; of which 1440 was excluded after
duplication, title and abstract screen. Thirty-four articles were reviewed after screening
for relevance. Twenty-two abstracts were analyzed and nine were used for inclusion in
this review. Based on Johns Hopkins Nursing Evidence-Based Practice appraisal form
(Appendix C) (Johns Hopkins Medicine, 2013), three out of the ten studies were levels
IB, and six out of ten were IIB evidence level and quality grade. Six out of the ten
studies utilized an HPV educational video as an intervention. Two of the ten studies
utilized HPV focused educational sessions, and one study analyzed 34 studies to look
at interventions used to increase community demand for HPV vaccinations that included
utilization of video technology in delivering messages about HPV vaccine.
Four of the articles included were quasi-experiment, two were randomizedcontrolled study, one cross-sectional voluntary pilot study, one was a review of literature
using randomized-controlled study and the last one was a review of literature of peer
reviewed articles. Most of the studies were done in a college campus, assessing
knowledge post intervention. Two studies were implemented in an OBGYN or women’s
health clinic across the U.S. Sample size varied from sixty participants to four hundred
and four.
Most studies utilized pre- and post-intervention tests; and examined knowledge
level before and after HPV educational video, HPV focused education or utilization of
technology or multimedia. Two studies found that there is a low baseline knowledge of
11
HPV and HPV vaccine in college students. Most of the studies showed that utilizing an
educational video increased knowledge post intervention, and retention of information in
college students from one to three months.
The literature review and data analysis showed that educational video is
an effective tool that can be used to increase HPV knowledge and retention. Therefore,
the documentary called “Someone You Love: The HPV epidemic” can be used
effectively to educate and increase knowledge of HPV and HPV vaccine.
Methods
Setting
The Edinboro University Institutional Review Board approved the study protocol
and a university conference room was set up for the project implementation. The
educational session was scheduled for March 26, 2018 from 11am- 2pm and 5-7pm.
Study Design
This is a quasi-experimental study, consisting of an eight pre-intervention and postintervention test.
Participants Recruitment
Participants were recruited from a university in northwest PA and surrounding
communities. The total enrollment for 2016 at the university was 6,181students. The
student population is diverse coming from 34 countries, 49 states, and 67 Pennsylvania
counties. There are 61.8% Women, and 38.2% Men enrolled. The Ethnic composition
was 82.3% White, 14.3% African American, Hispanic, Asian and other 3.3% Multiracial/ethnic. In-state residents is campus was 82.5%, out of state is 16.1% and 1.4%
12
are international students (Edinboro University, 2017). Any willing and interested
participants were also included.
Recruitment methods included posted event fliers around the campus and
community, and mass emails of the event sent to students and faculty at the university.
Anyone interested in the event self-selected to participate. A cover letter was given to
participants explaining the purpose of the study and assuring confidentiality and
anonymity. It also explained that completion of questionnaires was implied consent to
participate in the study. A separate survey from the DOH was given to participants,
which were shared with the DOH for data collection.
Inclusion and Exclusion Criteria
Inclusion criteria included anyone age18 yrs. old and older and able to speak,
read and understand English. Exclusion criteria is anyone who under 18 years of age
and is not able to speak, read and understand English.
Participants Demographic
There was a total of twenty-two participants. Seven were males and fifteen were
females. Twenty-one were in between ages 18-26 years old. Seventeen of the
participants were white/Caucasians, two were Hispanic/Latino, one Black/African
American and two identified themselves as “other” in regard to race and ethnicity.
Sixteen of the participants had some college credit, no degree as highest level of
education achieved. Three selected diploma or the equivalent (GED), one with
Bachelor’s degree and one with Doctorate degree.
13
Instrument
The instrument used for knowledge assessment consisted of eight questions that
were self-authored based on the review of literature, and previously used tools in other
research studies. The questions created were regarded by the author to be the best tool
to assess the knowledge level where knowledge would be low.
Intervention
An eight-question survey was giving prior to the educational session which
consisted of viewing “Someone You Love: The HVP epidemic”, followed by question
and answer session from a panel of experts on HPV. Following the session, the same
eight question test was given to participants. An additional survey questionnaire created
by the PA DOH was taken by participants post intervention.
Data Analysis
The pre- and post- test were compared for change in knowledge. Table 1. lists
the scores of the pre- and post-tests. Table 2. lists the questions and the percentage of
improvement post educational session per question. Figure 1. is the summary results of
a paired t-test for the two datasets at 95% confidence interval. The histogram of
differences between previewing scores and post viewing scores is also included. Figure
2. is the before and after Poisson capability comparison analysis summary.
The average score of the test before viewing the educational video is 77% and
93% after the educational session. The paired t-test indicate a significant statistical
difference between the two results with p-value of < .005 (.0003) and a t-value of -4.31
which represents the magnitude of variation in the test scores. The capability
14
comparison test on the incorrect data to determine the effect viewing the educational
video show the change of getting a perfect score on the post- test improved from 79.7%
to 93.4%. When the incorrect answers are regarded as a defect among the 22 tests,
showing the educational video reduced the incorrect answers by 70%.
Question 8: the HPV virus causes genital warts, question 2: HPV does not cause
cancers of the head or neck and question 6: Most people who contract HPV from a
partner will not have any symptoms of HPV disease were the most frequently missed
question; and had the most percentage improvement in post-test. This supports the
research that there is low knowledge regarding HPV, and low perceive risk.
Discussion
The study’s result showed an increase in knowledge among the participants post
educational intervention. This has implications on learning; that a focused educational
video on HPV can be utilized to increase knowledge. A limitation to this study is the
small sample size, thus it cannot be generalized. In addition, causality in this case can’t
be suggested in a pre- and post-test design with a small sample size. However, the
study reflects current literature that a focused educational video aids in increasing
knowledge in participants. In addition, the instrument used is self-authored and did not
undergo rigorous reliability and validity test. But in a study of this magnitude, this is not
necessary. The questions however, were reviewed and approved by a content expert
on HPV.
15
Conclusion
Seventy-nine million Americans are infected with HPV virus that can cause
cancer. The use of media to enhance teaching and learning, and ultimately knowledge
has been used for decades. An educational video can be a powerful learning
experience by increasing student’s engagement and knowledge retention. It also
complements and diversify traditional approaches to learning. Increasing knowledge of
HPV and HPV vaccine can aid in decreasing the prevalence and incidence of HPV
infection.
The study results showed a statistically significant increase in the participants
knowledge after the focused educational intervention (p = <.005). Therefore, the use of
an educational video such as “Someone you love: The HPV epidemic” along with a brief
question and answer can be utilized as a powerful tool to increase knowledge. Further
study is needed to assess generality by increasing the number of participants in varied
settings. Future research is needed to assess whether increase knowledge of HPV and
HPV vaccine leads to increase vaccination and compliance to series completion.
16
References
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vaccinated against HPV: Attitudes, intentions and perceived barriers of female
undergraduates. College Student Journal, 44(1), 55-63.
Centers for Disease Control and Prevention. (2017). Clinician FAQs: CDC
Recommendations for HPV Vaccine 2-Dose Schedule. Retrieved from
https://www.cdc.gov/hpv/hcp/2-dose/clinician-faq.html
Centers for Disease Control and Prevention. (2018). HPV-associated cancer diagnosis
by age. Retrieved from https://www.cdc.gov/cancer/hpv/statistics/age.htm
Centers for Disease Control and Prevention (2016). HPV vaccine information for
clinicians-Fact sheet. Retrieved from http://www.cdc.gov/std/hpv/stdfact- hpvvaccine-hcp.htm
Centers for Disease Control and Prevention. (2016). HPV vaccine recommendation.
Retrieved from https://www.cdc.gov/vaccines/vpd/hpv/hcp/recommendations.html
Centers for Disease Control and Prevention. (2017). Human papillomavirus. Retrieved
from https://www.cdc.gov/hpv/
Centers for Disease Control and Prevention. (2015). Immunization strategies for
healthcare practices and providers. Retrieved from
https://www.cdc.gov/vaccines/pubs/pinkbook/downloads/strat.pdf
Centers for Disease Control and Prevention. (2015). Many adolescents still not getting
HPV vaccine. Retrieved from https://www.cdc.gov/media/releases/2015/p0730hpv.html
17
Centers for Disease Control and Prevention (2016). National, Regional, State, and
Selected Local Area Vaccination Coverage Among Adolescents Aged 13–17
Years — United States, 2015. Morbidity and Mortality Weekly Report (MMWR).
Retrieved from
https://www.cdc.gov/mmwr/volumes/65/wr/mm6533a4.htm#T3_down
Centers for Disease Control and Prevention. (2013). New study shows HPV vaccine
helping lower HPV infection rates in teen girls. Retrieved from
https://www.cdc.gov/media/releases/2013/p0619-hpv-vaccinations.html
Chesson, H.W., Ekueme, D.U., Saraiya, M., Watson, M., Lowy, D.R., & Markowitz, L.E.
(2012). Estimates of the annual direct medical costs of the prevention and
treatment of disease associated with human papillomavirus in the United States.
NCBI,14;30(42), 6016-6019.
Crawford County Health Improvement Coalition.
http://crawfordcountypartnership.org/2016/04/12/protect-against-hpv-project2016/. Accessed March 25, 2018.
Dillard, J.P., & Spear, M.E. (2010). Knowledge of human papilloma virus and perceived
barriers to vaccination in a sample of US female college students. Journal of
American College Health, 59(3), 186-190.
Edinboro University (2017). Edinboro University fact sheet 2016-2017. Retrieved from
http://www.edinboro.edu/about/fact%20sheet%20one-pager%2012-16.pdf
Garcia, J. (2013). A review of barrier to HPV vaccination among teen. Medscape.
Retrieved at http://www.medscape.com/viewarticle/814968
18
Holman, D.M., Roland, K.B., Watson, M., Liddon, N., & Stokley, S. (2014). Barriers to
human papillomavirus vaccination among U.S. adolescents: A systematic review
of literature. JAMA Pediatric, 158(1), 76-82.
John’s Hopkins Medicine. Johns Hopkins Nursing Evidence-Based Practice Mode.
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Krawczyk, A., Lau, E., Perez, S., Delisle, V., Amsel, R., & Rosberger, Z. (2011). How to
inform: Comparing written and video education interventions to increase Human
Papillomavirus knowledge and vaccination intentions in young adults. Journal of
American College Health, 60(4), 316-322.
Lambert, E.C. (2001). College students’ knowledge of human papillomavirus and
effectiveness of a brief educational intervention. J Am Board Fam Prac, 14(3),
178-83.
Marchand, E., Glenn, B.A., & Bastani, R. (2012). Low HPV vaccine coverage among
female community college students. J Community Health, 37(6), 1136-1144.
McQuillan, G., Kruszon-Moran, D., Markowitz, L.E., Unger, E.R., & Paulose-Ram, R.
(2017). Prevalence of HPV in Adults Aged 18–69: United States, 2011–2014.
NCHS. National Health and Nutrition Examination Survey, Retrieved from
https://www.cdc.gov/nchs/products/databriefs/db280.htm
Navalpakam, A., Dany, M., & Hussein, I., H. (2016). Behavioral perceptions of Oakland
University female college students towards human papilloma virus vaccinations.
PLos One, 11(5). doi: 10.1371/journal.pone.0155955.
19
Ratanasiripong, N. (2012). A Review of Human Papillomavirus (HPV) Infection and HPV
Vaccine–Related Attitudes and Sexual Behaviors Among College-Aged
Women in the United States. Journal of American College Health, 60(6), 461470. doi:10.1080/07448481.2012.684365
Reagan-Steiner, S., Yankey, D., Jeyarajah, J., Elam-Evans, L., Curtis, R., MacNeil, J.,
Markowitz, L., and Singleton, J.(2016). National, regional, state and selected
local area vaccination coverage among adolescents aged 13-17 years-United
States, 2015. MMWR Morb Mortal Wkly Rep., (65) 850-858. Retrieved from
https://www.cdc.gov/mmwr/volumes/65/wr/mm6533a4.htm. Doi:
http://dx.doi.org/10.15585/mmwr.mm6533a4
Rosenblatt, L. (2016). Allegheny county considers mandate for HPV vaccine for
students. Post Gazette. Retrieved from http://www.postgazette.com/news/education/2016/06/22/Allegheny-County-invites-publiccomment-on-proposed-HPV-mandate-for-schoolchildren/stories/201606220140
Sheaves, C.G. (2016). Influence of education strategies on young women’s knowledge
and attitudes about the HPV vaccine. NPWH, 4(4). Retrieved from
https://npwomenshealthcare.com/influence-education-strategies-young-womensknowledge-attitudes-hpv-vaccine/
Soper, D. (2006). Reducing the health burden of HPV infection through vaccination.
Infec Dis Obstet Gynecol. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1522061/
Warren, K. (2009). HPV knowledge among female college students and the short term
effectiveness of HPV education. Journal of Academic Physician Assistant, 7(2).
20
21
a college campus in rural Northwest PA improve the knowledge level of HPV
disease and vaccine among attendees of the program?
Dianne Luc
Clarion and Edinboro Universities
Spring 2018
Colleen R. Bessetti-Barrett, DNP, CRNP, FNP-BC – Co-author, Committee Chair
Jill Rodgers, DNP, CRNP, FNP-BC – Program Advisor, Committee Member
Karen Wiggers, RN, BSN – Committee Member
Dedication
My DNP project is dedicated to my family whose unwavering support and
understanding enabled me to realize my dream. To my husband, for all the sleepless
nights taking care of our children, listening to my frustrations and putting up with my
petulance. To my children Ethan, Anthony, and Angelina Rose who give me strength
and purpose. May you look back and understand the moments in your life when I was
not there for your karate tournaments and playdates. And may you be encouraged and
be proud of me. To my mom and dad, my number one cheerleaders, thank you for
always believing in me and for pushing me to keep reaching for the stars. Your
optimism, encouragement, and love have pushed me though many difficult and
challenging moments. You both have been the shining light that guided me not only
through my studies but throughout my life. To my siblings, whom I call on last minute
for miscellaneous things. Special gratitude from the bottom of my heart to my sister
Joyce for your uplifting spirit and all your help. Thank you for always being there when I
need you. To my parents-in-law and my sister-in-law, Jodie, for babysitting and making
sure I am healthy. As I reflect on my journey, I feel blessed that I have all of you in my
life. Thank you for walking this journey with me.
ii
Acknowledgements
I would like to acknowledge and express my sincere gratitude to my DNP
committee for their expertise, support, and guidance. Your advice and knowledge were
vital to the successful completion of my project. I would like to thank all the professors
who have guided me along the way. To Dr. Bessetti-Barrett, for your patience and
understanding in every situation and for your guidance and sharing your immense
knowledge with me. To Dr. Rodgers, for being a great professor and for helping me
grow. To Karen, for providing insight and resources that helped assist with the study.
And finally, to Edinboro University, for providing the conference room and the
environment for me to implement my DNP project.
Colleen R. Bessetti-Barrett, DNP, CRNP, FNP-BC – Co-author, Committee Chair
Jill Rodgers, DNP, CRNP, FNP-BC – Program advisor, Committee Member
Karen Wiggers, RN, BSN – Committee Member
iii
Table of Contents
Dedication.........................................................................................................................ii
Acknowledgements……………………………………………………………………….….…iii
Table of Contents.............................................................................................................iv
Tables and Figures..........................................................................................................vi
Abstract.............................................................................................................................x
Background.......................................................................................................................1
HPV Vaccine Reccomendations.......................................................................................2
HPV Vaccine Statistics……………………………………………………………………...….3
Economic Burden…………………………………………………………………………....….4
Barriers………………………………………………………………………………………......5
Strategies……………………………………………………………………………………...…6
HPV Knowledge, Perceptions and Vaccination Rate Among College Students………....6
HPV Initiatives in Pennsylvania…………………………………………………………….….8
Statement of the Problem…………………………………………………………………….10
Synthesis of Evidence…………………………………………………………………………10
Methods..........................................................................................................................12
Setting.............................................................................................................................12
Study Design……………………………………………………………………...……………12
Participant Recruitment…………………………………………………………………….....12
Inclusion and Exclusion Criteria......................................................................................13
Participant Demographic…………………………………………………………………...…13
iv
Insturment......................................................................................................................14
Intervention………………………………………………………………………………….….14
Data Analysis……………………………………………………………………………….….14
Discussion………………………………………………………………………………………15
Conclusion…………………………………………………………………………………...…16
References……………………………………………………………………………………..17
v
Tables and Figures
Table 1. Test Scores Before and After Education Video
Student
Before
After
1
4/8
8/8
2
8/8
8/8
3
7/8
8/8
4
8/8
8/8
5
7/8
8/8
6
7/8
8/8
7
5/8
7/8
8
6/8
7/8
9
3/8
7/8
10
6/8
8/8
11
7/8
7/8
12
5/8
7/8
13
5/8
8/8
14
5/8
8/8
15
5/8
8/8
16
6/8
6/8
17
7/8
7/8
18
7/8
7/8
19
7/8
7/8
20
7/8
8/8
21
8/8
8/8
22
6/8
6/8
vi
Table 2. Questions and the percentage of improvement post educational session
Question
1. HPV is a common sexually transmitted infection.
% Improvement
Post Training
9
2. HPV causes cervical cancer.
14
3. HPV does not cause cancers of the head or neck.
23
4. Men can become infected with the HPV virus.
9
5. Only women can become infected with the HPV virus.
14
6. Most people who contract HPV from a partner will not have any symptoms of
HPV disease.
7. There is a vaccine available to help prevent certain types of HPV infections.
23
8. The HPV virus causes genital warts.
27
vii
9
Figure 1. Paired T-Test and CI: correct pre, correct post
Descriptive Statistics
Sample
N
Mean
StDev
SE Mean
correct pre
22
6.182
1.332
0.284
correct post
22
7.455
0.671
0.143
Estimation for Paired Difference
Mean
StDev
SE Mean
-1.273
1.386
0.296
95% CI for
μ_difference
(-1.887, -0.658)
µ_difference: mean of (correct pre - correct post)
Test
Null hypothesis
H₀: μ_difference = 0
Alternative hypothesis
H₁: μ_difference ≠ 0
T-Value
P-Value
-4.31
0.000313
Histogram of Differences
(with Ho and 95% t-confidence interval for the mean)
10
8
Frequency
6
4
2
0
_
X
Ho
-4
-3
-2
Differences
viii
-1
0
Figure 2. Capability Comparison Analysis
Before/After Poisson Capability Comparison for incorrect pr vs incorrect po
Summary Report
Process Characterization
Reduction in Defects per Unit (DPU)
70%
DPU was reduced by 70% from 0.227 to 0.068.
Is the DPU at or below 0?
0.0
0.05
Before
After
22
8
176
40
22
8
176
12
Number of subgroups
Subgroup size
Total units tested
Total defects
0.1
> 0.5
Yes
Process Capability (Overall)
No
No test is performed when you set the maximum acceptable DPU to 0.
DPU
95% CI
Yield
Before
After
Change
0.227
(0.162, 0.309)
79.7%
0.068
(0.035, 0.119)
93.4%
-0.159
13.7%
Yield is the chance of producing a unit with no defects.
Observed DPU per Subgroup
Where are the data relative to the acceptable level?
Comments
0
Before: Average DPU = 0.227
Before: incorrect pr
Acceptable DPU: 0
After: incorrect po
• Before: The process DPU was greater than the maximum acceptable level
of 0.
• After: The process DPU is greater than the maximum acceptable level of 0.
• The chance of producing a unit with no defects improved from 79.7% to
93.4%.
After: Average DPU = 0.068
0.0
0.1
0.2
0.3
0.4
0.5
0.6
ix
Abstract
Human Papillomavirus (HPV) is the most common sexually transmitted infection
causing cervical, oropharyngeal cancers and genital warts. In the United States (U.S.), it
is estimated that one in four individuals are infected, with an additional 14 million new
cases of HPV infections occurring annually. HPV contributes to 17,600 cancers in
women and 9,300 cancers in men annually. HPV vaccine is the most effective way to
protect against HPV related cancers. However, there is a lag in HPV vaccination due to
barriers such as: health care providers hesitancy to promote the HPV vaccine, low
baseline knowledge of HPV and HPV vaccine, safety concerns, cost and system
barriers. Studies show that there is low overall knowledge of baseline HPV and HPV
vaccine among college students. The purpose of this study is to determine if an
educational video intervention increases baseline knowledge of HPV and HPV vaccine
in the attendees on a college campus in Northwestern Pennsylvania. To test this, a
study design consisting of an educational session that utilizes an HPV educational
video, followed by a brief question and answer session was developed. A questionnaire
is implemented pre- and post-intervention to analyze HPV knowledge in participants.
There were 22 participants who completed the study. Comparison analysis between the
pre- and post-knowledge assessments show statistically significant improvement of
results after viewing the educational documentary on HPV. The likelihood of getting a
perfect score on the assessment increased by 13.7%, equating to a 70 percent
reduction of incorrect answers from viewing the educational video.
x
Does viewing an educational documentary about HPV disease and vaccination
on a college campus in rural Northwest PA improve the knowledge level of HPV disease
and vaccine among attendees of the program?
Background
Human Papillomavirus (HPV) is a common virus that is associated with skin
warts, anogenital, oropharyngeal and cervical cancer (Centers for Disease Control and
Prevention [CDC], 2017). In the United States (U.S.) alone, an estimated 79 million
individuals are infected, with an additional 14 million new cases of HPV infections
occurring yearly. HPV contributes to 17,600 cancers in women and 9,300 cancers in
men annually (CDC, 2017). HPV vaccine is the most effective and safest protection
against HPV related cancers. Although there is an increase in HPV vaccination since
its introduction in 2006, it remains disproportionately low in comparison to other
adolescent vaccines. Four out of ten adolescent girls, and six out of ten adolescent
boys are unvaccinated against HPV, and are vulnerable to cancer (CDC, 2015).
HPV is transmitted through skin to skin contact, mostly through sexual activity
with an infected individual. There are over 120 HPV types that have been identified.
Forty of them are associated with cervical cancer. Low risk or non-oncogenic types
such as types 6 and 11 causes genital warts, and laryngeal papillomas. High risk or
oncogenic HPV types results in cervical, anogenital and oropharyngeal cancers. More
than 99% of cervical cancer is related to HPV; and type 16 and 19 accounts for about
70% of cervical cancers (Warren, 2009).
1
In the U.S. about 11,000 women are diagnosed with cervical cancer, and about
4,400 of those women die annually (CDC, 2013). In men, oropharyngeal cancer is the
most common cancer cause by HPV. HPV causes 91% of anal cancers, 75 % of
vaginal cancers, 69 % of vulvar cancer, and 63 % of penile cancers (CDC, 2018).
About one in 100 sexually active adults in the U.S. has genital warts at any given time.
The highest rate of new HPV infections is between the ages of 15-24 years old (CDC,
2013).
The National Health and Nutrition Examination Survey (NHANES) 2011–2014,
provided some statistics regarding HPV among adults aged 18 to 59 years old. The
prevalence of oral HPV for adults during 2011 to 2014 was 7.3%, and high-risk HPV
was 4.0%. Data from 2013 to 2014 showed that prevalence of any and high-risk genital
HPV was 45.2% and 25.1% in men and 39.9% and 20.4% in women, respectively.
“Prevalence of any and high-risk oral HPV was overall lowest among non-Hispanic
Asian adults and was highest among non-Hispanic black adults. Prevalence of any and
high-risk oral HPV was higher in men than women except for high-risk HPV among
Asian adults. Prevalence of any and high-risk genital HPV was lower among nonHispanic Asian and higher among non-Hispanic black than both non-Hispanic white and
Hispanic men and women” (McQuillan, G., Kruszon-Moran, D., Markowitz, L.E., Unger,
E.R., & Paulose-Ram, R., 2017).
HPV Vaccine Recommendation
The CDC and Advisor Committee on Immunization Practices (ACIP) updated the
HPV vaccine recommendation in October of 2016. The new recommendation is for 11
2
or 12-year-old boys and girls to receive two doses of HPV vaccine instead of three
doses for individuals starting the vaccination series before the age of 15 years old.
Vaccinations needs to be 6 to 12 months apart. Three doses of HPV vaccine are
recommended for individuals starting the vaccination series on or after the 15th
birthday, and for people with certain immunocompromising conditions (CDC, 2017).
ACIP recommends female vaccination at aged 13 through 26; and for males aged 13
through 21 for persons without adequate vaccination in the past. Immunocompromised
individuals, transgender adults, and males who are bisexual, transgender or who plan to
have sex with other men are recommended to get the three-series schedule: 0, 1-2
months, 6 months; and can be vaccinated until the age of 26. The vaccination series
can still be started at age 9 (CDC, 2016). This change was recommended by the CDC
and the ACIP after data showed that the antibody responses after two doses given at
least 6 months apart to 9-14 years old was as good or even better than the three doses
given to older adolescents and young adults, the age group in which efficacy was
demonstrated in clinical trials (CDC, 2017). Ideally, vaccination should be administered
prior to HPV exposure. Thus, it is recommended to vaccinate adolescents prior to their
first sexual encounter (CDC, 2016).
HPV Vaccine Statistics
HPV vaccine uptake is low when compared to other adolescent vaccines. In
2015 among males, coverage with ≥1 HPV vaccine dose was 49.8% and with ≥3 doses
was 28.1%. The females’ coverage with ≥1 dose was 62.8% and with ≥3 doses was
41.9%. This shows that there were less series completion compliance. In 2015, among
all adolescents (females and males combined), HPV vaccination coverage with ≥1 dose
3
was 56.1% (95% CI = 54.9%–57.4%), with ≥2 doses was 45.4% (95% CI = 44.2%–
46.7%), and with ≥3 doses was 34.9% (95% CI = 33.7%–36.1%). Among all
adolescents, coverage with ≥1 HPV vaccine dose was 30.3 % points lower than
coverage with ≥1 Tdap dose and 25.2 % points lower than coverage with ≥1 MenACWY
dose (CDC, 2016; Reagan-Steiner,2016). Thus, HPV vaccine uptake is lagging
compared to other adolescent vaccines.
Pennsylvania (PA) is above the national vaccine coverage average with
coverage among males, coverage with ≥1 HPV vaccine dose was 55.9% and with ≥3
doses was 47.8%. The females coverage with ≥1 dose was 62.2% and with ≥3 doses
was 47.8% (CDC, 2016). However, HPV vaccine uptake remains low with low
compliance to complete the vaccination series. Therefore, strategies to
increase HPV uptake is vital in preventing HPV-related disease (CDC, 2016).
Economic Burden
HPV infections causes economic burden. An estimated $8.0 billion annual direct
medical cost is spent on prevention and treatment of HPV infections (Chesson et al.,
2012). Although genital warts and other low-grade types are medically benign, and can
resolve on its own, diagnosis of genital warts or an abnormal Pap smear is costly, and
results in emotional distress. Another study by Soper (2006) estimated that $3.4 billion
is spent annually on diagnosis and treatment of HPV infection and its associated
cervical diseases. About 90% of the estimated cost is due to preventative measures
such as treatment of precancerous lesions and routine Pap tests. The remaining 10%
is attributed to treatment of cervical cancer.
4
Most of the burden of HPV associated healthcare cost is seen in adolescents and
young adults. According to Sober (2006), the estimated lifetime total medical cost of
HPV infection for men and women aged 15–24 is $2.9 billion. Additionally, an annual
total direct medical cost for treatment of anogenital warts in all age groups for the year
2000 was $167.4 million. It is apparent that HPV related infection produces a significant
economic burden. HPV vaccine can help prevent HPV infections which will increase
quality of life, decrease health care cost significantly, therefore producing a healthier
population. Promotion of HPV vaccine and effective strategies to tackle the low uptake
of HPV vaccine disease is vital (CDC,2017).
Barriers
According to CDC, missed clinical opportunities is the most important reason for
the low HPV vaccine uptake. Many vaccine-eligible adolescents do not receive HPV
vaccines, while receiving at least one other vaccine. Other factors contributing to the
low utilization of HPV vaccinations include:
•
health care providers hesitancy to promote and vaccinate due to knowledge gap
•
lack of overall knowledge of HPV leading to misinformation
•
discomfort of practitioners regarding sexual behaviors
•
cost
•
safety and efficacy
System barriers such as lack of tools to remind practitioners, time constraints are
prominent contributing problems. (Holman et al., 2014). In the underserved
populations, limited knowledge about the vaccine is more pronounced, cultural
5
differences, insurance coverage and immigration status increased resistance to HPV
vaccination (Garcia, 2013). Barriers to vaccination in the college students noted were
side effects, costs, and lack of basic knowledge regarding HPV and HPV vaccination
(Burke et al., 2010).
Strategies
Strategies used to combat this public health threat includes effective education,
implementation of tools such as the AFIX approach recommended by the CDC,
reminder and recall systems, assessment and feedback, and other tools reminding
providers to check immunization history, as well as strong consistent recommendation
and promotion by providers for the HPV vaccine (CDC, 2018). Increase in collaboration
and communication within health care providers are also imperative. One of the
Healthy People’s objectives for 2020 is to increase HPV vaccine series among U.S.
female age 13-15 years old by 80 percent. Efforts that address system-level barriers to
vaccination will help to increase overall HPV vaccine uptake (Holdman et al., 2014).
Health care providers need to actively take on the responsibility and make HPV
vaccination a public health priority in order to save lives.
HPV knowledge, perception, and vaccination rate among college students
Knowledge of HPV and HPV vaccine in college students is low. A study by
Lambert (2001) evaluated knowledge in two groups of college students who were
subjected to HPV focused education that consisted of pre and post intervention
questionnaires three months apart. The results showed that the participants had low
overall knowledge regarding HPV disease. However, there was a statistically significant
improvement of HPV knowledge post interventions. Dillard and Spear (2010) assessed
6
knowledge of HPV and perceived barriers to being vaccinated against HPV virus at
Penn State University and found that although awareness of HPV and HPV virus was
high; only 65% had knowledge of HPV related facts. The lack of knowledge about HPV
is a common barrier to HPV vaccine uptake (Sheaves, 2016)
The perception of low risk for HPV and institutional barriers were cited as the
most common reasons for parent’s refusal to vaccinate their children (Navalpakam et
al., 2016). A literature review regarding attitudes and sexual behavior among women
college students in the U.S. showed that the women perceived HPV infection as a
serious health risk and had a positive outlook on HPV vaccine; but many do not
perceive themselves at risk (Ratanasiripong, 2012). This is also echoed by another
study at Oakland University of female college students with the majority of the
participants perceived that HPV is life threatening and prevents cervical cancer;
however, about 50% of the participants did not believe they were at risk (Navalpakam et
al., 2016). Effective unbiased education regarding HPV and HPV vaccine to increase
knowledge with the emphasis of risk to the individual is an important aspect of HPV
focused education.
A study assessing HPV vaccination and its correlation among culturally diverse
18-26-year-old community college women in Los Angeles, looked at what proportion of
the respondents have started the HPV vaccine, and what proportion have completed
the vaccine series. Additionally, it looked at what variables such as demographics,
psychosocial, and health care related issues are linked to vaccines initiation for the
respondents. The results show that those who started the vaccine series were younger,
more often had a health-related academic major, believed that HPV vaccine was safer,
7
perceived HPV severity lower, and perceived higher social approval for the vaccine than
those who were unvaccinated. All the respondent who initiated the vaccine received
recommendation for the vaccine from their health care provider (Marchand et al., 2012).
In addition, a study of a southeastern university showed that out of the 875
survey respondents, only 78.6% indicated that they would get vaccinated. Out of the
respondents who self-identified as not yet sexually active; only 60.7% plan to get
vaccinated. Respondents concern about vaccine safety, side-effects, cost and lack of
knowledge were common barriers noted (Burke et al., 2010). Thus, increasing
knowledge regarding HPV and HPV vaccine through focused educational efforts is
needed to improve HPV knowledge, and decrease HPV related infections.
HPV initiatives in Pennsylvania
In an effort to increase HPV awareness and promote HPV vaccination, the PA
Department of Health (DOH) has created a powerful documentary called “Someone You
Love: The HPV epidemic”. The video follows five young women with HPV and shows
how HPV infection has affected their lives. The PA DOH has utilized healthcare
organizations to use the video as a tool to increase HPV knowledge and HPV
vaccination uptake. In 2016, the PA DOH had set up a program called PROTECT
Against HPV: A collaboration for community and provider outreach under Crawford
Health Improvement Coalition (CHIC) to utilize the video as a tool through a schoolbased campaign, a healthcare campaign and a community campaign (Crawford County
Health Improvement Coalition, 2016).
A post survey is completed following the showing of the video. According to the
data collected and presented on June 13, 2017, “Someone you love: The HPV
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epidemic” video was shown in six locations in PA: Dietrich Theater Trunkhannock
(N=42), Meadville (N=34), Temple University in Harrisburg (N=13), Titusville (N=8),
Mechanicsburg (N=1), and online (N=1). The total sample size was N=99 participants.
Most of the participants heard about the program through others: email, phone blast,
school (36.4%), friends (21.8%), flyer (17.3%), Newspaper (8.2%), health care provider
(7.2%), social media (6%) and movie ad (4%). Only N=93 of the participant responded
to the questionnaire.
The participants average age is approximately 38.7 years old, consisting of
parent/guardian (28.5%), community member (21.5%), health care provider (17.7%),
student (15.1%), grandparent (9.1%) and educator (8.1%), with total responders of
N=98. There was a significant increase of support for HPV vaccination post viewing.
“Very supportive” of HPV vaccination increased from 45.9% to 85.9%, “supportive” from
29.6% to 11.15%, and “still undecided” decreased from 5% to 3%. Prior to the viewing,
9.2% had no knowledge of HPV and HPV vaccine. No individuals in the study were “not
supportive” pre and post viewing. The total respondents pre-viewing was N=98 and
post-viewing was N=99. Post-viewing, 58.6% chose “I will encourage those I know to
get the HPV vaccination”, 31.5% chose “I will get myself/my child all 3 HPV shots”, and
9.9% chose “I will talk to my healthcare provider about getting the HPV vaccination”.
The last question was not mutually exclusive, so respondents can pick one or more
answer to the question. Data from the effort show an increase in support for HPV
vaccination post-viewing. Knowledge however, was not assessed specifically postviewing. Strategies incorporating focused educational videos have proven to be an
effective tool to increase knowledge (Krawczyk, 2011).
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Statement of the problem
HPV vaccine uptake has been lagging compared to other adolescent vaccines.
Studies show that knowledge of HPV and HPV vaccine in college students are low.
This is concerning since vaccination is the best prevention measure against HPV
infections. In Pennsylvania, only 48.2 percent of females between 13 and 17 years old
and 26 percent of males received all three shots in 2014. While in the Pittsburgh region,
27 percent of girls and 21.8 percent of boys ages 14-17 were fully vaccinated in 2014
(Rosenblatt, 2016). The objective of this scholarly study is to add to the literature by
examining whether a focused educational video on HPV and the HPV vaccine such as
the video, “Someone You Love: The HPV Epidemic”, increases baseline knowledge
among the participants. A secondary goal is to aid and contribute to the PA DOH’s data
collection in an effort to spread awareness though the promotion on the educational
video.
Synthesis of evidence
A search of literature was performed to answer the question: Does viewing an
educational documentary about HPV disease and vaccination on a college campus in
rural Northwest PA improve the knowledge level of HPV disease and vaccine among
attendees of the program? The search was performed using Cumulative Index of
Nursing and Allied Health Literature (CINAHL), Medline, PubMed and EBSCO
databases. The search terms that were used were: “HPV vaccine”, AND “increase
knowledge”, and “educational video”. Limits placed included: English language, items
with abstracts, full text articles, time frame range from 2001-2017, geography to USA.
Inclusion criteria included articles related to increasing HPV vaccination, educational
10
videos, increase knowledge. Exclusion criteria included any article that did not pertain
to increasing knowledge with the use of educational or training video, and any studies
done outside U.S.
The search engines yielded 1452 results; of which 1440 was excluded after
duplication, title and abstract screen. Thirty-four articles were reviewed after screening
for relevance. Twenty-two abstracts were analyzed and nine were used for inclusion in
this review. Based on Johns Hopkins Nursing Evidence-Based Practice appraisal form
(Appendix C) (Johns Hopkins Medicine, 2013), three out of the ten studies were levels
IB, and six out of ten were IIB evidence level and quality grade. Six out of the ten
studies utilized an HPV educational video as an intervention. Two of the ten studies
utilized HPV focused educational sessions, and one study analyzed 34 studies to look
at interventions used to increase community demand for HPV vaccinations that included
utilization of video technology in delivering messages about HPV vaccine.
Four of the articles included were quasi-experiment, two were randomizedcontrolled study, one cross-sectional voluntary pilot study, one was a review of literature
using randomized-controlled study and the last one was a review of literature of peer
reviewed articles. Most of the studies were done in a college campus, assessing
knowledge post intervention. Two studies were implemented in an OBGYN or women’s
health clinic across the U.S. Sample size varied from sixty participants to four hundred
and four.
Most studies utilized pre- and post-intervention tests; and examined knowledge
level before and after HPV educational video, HPV focused education or utilization of
technology or multimedia. Two studies found that there is a low baseline knowledge of
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HPV and HPV vaccine in college students. Most of the studies showed that utilizing an
educational video increased knowledge post intervention, and retention of information in
college students from one to three months.
The literature review and data analysis showed that educational video is
an effective tool that can be used to increase HPV knowledge and retention. Therefore,
the documentary called “Someone You Love: The HPV epidemic” can be used
effectively to educate and increase knowledge of HPV and HPV vaccine.
Methods
Setting
The Edinboro University Institutional Review Board approved the study protocol
and a university conference room was set up for the project implementation. The
educational session was scheduled for March 26, 2018 from 11am- 2pm and 5-7pm.
Study Design
This is a quasi-experimental study, consisting of an eight pre-intervention and postintervention test.
Participants Recruitment
Participants were recruited from a university in northwest PA and surrounding
communities. The total enrollment for 2016 at the university was 6,181students. The
student population is diverse coming from 34 countries, 49 states, and 67 Pennsylvania
counties. There are 61.8% Women, and 38.2% Men enrolled. The Ethnic composition
was 82.3% White, 14.3% African American, Hispanic, Asian and other 3.3% Multiracial/ethnic. In-state residents is campus was 82.5%, out of state is 16.1% and 1.4%
12
are international students (Edinboro University, 2017). Any willing and interested
participants were also included.
Recruitment methods included posted event fliers around the campus and
community, and mass emails of the event sent to students and faculty at the university.
Anyone interested in the event self-selected to participate. A cover letter was given to
participants explaining the purpose of the study and assuring confidentiality and
anonymity. It also explained that completion of questionnaires was implied consent to
participate in the study. A separate survey from the DOH was given to participants,
which were shared with the DOH for data collection.
Inclusion and Exclusion Criteria
Inclusion criteria included anyone age18 yrs. old and older and able to speak,
read and understand English. Exclusion criteria is anyone who under 18 years of age
and is not able to speak, read and understand English.
Participants Demographic
There was a total of twenty-two participants. Seven were males and fifteen were
females. Twenty-one were in between ages 18-26 years old. Seventeen of the
participants were white/Caucasians, two were Hispanic/Latino, one Black/African
American and two identified themselves as “other” in regard to race and ethnicity.
Sixteen of the participants had some college credit, no degree as highest level of
education achieved. Three selected diploma or the equivalent (GED), one with
Bachelor’s degree and one with Doctorate degree.
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Instrument
The instrument used for knowledge assessment consisted of eight questions that
were self-authored based on the review of literature, and previously used tools in other
research studies. The questions created were regarded by the author to be the best tool
to assess the knowledge level where knowledge would be low.
Intervention
An eight-question survey was giving prior to the educational session which
consisted of viewing “Someone You Love: The HVP epidemic”, followed by question
and answer session from a panel of experts on HPV. Following the session, the same
eight question test was given to participants. An additional survey questionnaire created
by the PA DOH was taken by participants post intervention.
Data Analysis
The pre- and post- test were compared for change in knowledge. Table 1. lists
the scores of the pre- and post-tests. Table 2. lists the questions and the percentage of
improvement post educational session per question. Figure 1. is the summary results of
a paired t-test for the two datasets at 95% confidence interval. The histogram of
differences between previewing scores and post viewing scores is also included. Figure
2. is the before and after Poisson capability comparison analysis summary.
The average score of the test before viewing the educational video is 77% and
93% after the educational session. The paired t-test indicate a significant statistical
difference between the two results with p-value of < .005 (.0003) and a t-value of -4.31
which represents the magnitude of variation in the test scores. The capability
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comparison test on the incorrect data to determine the effect viewing the educational
video show the change of getting a perfect score on the post- test improved from 79.7%
to 93.4%. When the incorrect answers are regarded as a defect among the 22 tests,
showing the educational video reduced the incorrect answers by 70%.
Question 8: the HPV virus causes genital warts, question 2: HPV does not cause
cancers of the head or neck and question 6: Most people who contract HPV from a
partner will not have any symptoms of HPV disease were the most frequently missed
question; and had the most percentage improvement in post-test. This supports the
research that there is low knowledge regarding HPV, and low perceive risk.
Discussion
The study’s result showed an increase in knowledge among the participants post
educational intervention. This has implications on learning; that a focused educational
video on HPV can be utilized to increase knowledge. A limitation to this study is the
small sample size, thus it cannot be generalized. In addition, causality in this case can’t
be suggested in a pre- and post-test design with a small sample size. However, the
study reflects current literature that a focused educational video aids in increasing
knowledge in participants. In addition, the instrument used is self-authored and did not
undergo rigorous reliability and validity test. But in a study of this magnitude, this is not
necessary. The questions however, were reviewed and approved by a content expert
on HPV.
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Conclusion
Seventy-nine million Americans are infected with HPV virus that can cause
cancer. The use of media to enhance teaching and learning, and ultimately knowledge
has been used for decades. An educational video can be a powerful learning
experience by increasing student’s engagement and knowledge retention. It also
complements and diversify traditional approaches to learning. Increasing knowledge of
HPV and HPV vaccine can aid in decreasing the prevalence and incidence of HPV
infection.
The study results showed a statistically significant increase in the participants
knowledge after the focused educational intervention (p = <.005). Therefore, the use of
an educational video such as “Someone you love: The HPV epidemic” along with a brief
question and answer can be utilized as a powerful tool to increase knowledge. Further
study is needed to assess generality by increasing the number of participants in varied
settings. Future research is needed to assess whether increase knowledge of HPV and
HPV vaccine leads to increase vaccination and compliance to series completion.
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