Knowledge of Cervical Cancer, Human Papilloma Virus (HPV) and HPV Vaccination Among Women in Northeast China

In 2013, the American Cancer Society (ACS) reported that 4030 patients died of CC among the 12,340 with newly diagnosed CC. The incidence of squamous cell carcinoma, which is sensitive to radiotherapy and has a good prognosis, is gradually decreasing, but the incidence of adenocarcinoma is increasing. In particular, the incidence of CC in younger women shows an increasing trend which is more obvious in developing countries. In China, the incidence of CC is second only to that of breast cancer as the disease which most seriously threatens women’s health. Since 2004, the Chinese government has been actively promoting and carrying out a CC screening program, including establishing pilot and demonstration sites for early intervention in patients with CC. Up to 2009, CC pilot sites had been established in 221 counties in 31 provinces or autonomous regions. Large-scale education and screening have significantly decreased the incidence and mortality of CC in China [7]. However, owing to a huge population base, the limited economic developmental level, unbalanced allocation of healthcare resources, and the low knowledge of the disease among Chinese women, China still lags behind developed countries in the prevention of CC. Notably, the incidence of CC in China is six times than that in developed countries and Chinese CC cases account for one-third of the cases in the world. Meanwhile, the incidence of the disease increases by 2–3% annually in China and every day about 100 Chinese women die of CC [4].

Fortunately, CC has a good prognosis if it can be screened, detected, and treated early. In this study, 43% of women said they could accept the current price of CC screening, and those who had undergone CC screening had higher recognition of CC and HPV than women who had not had CC screening. Therefore, the price of CC screening plays an important role in women’s awareness of CC and HPV. The price of CC screening varies among hospitals. This study hopes to provide some data to guide the pricing policy for CC screening. Appropriately reducing the price of CC screening or including it in outpatient health insurance coverage would allow more people to have the opportunity to undergo CC screening. At the same time, promoting relevant knowledge from all aspects will ensure that most people understand the screening and regularly attend a hospital for examination. There is a long way to go to achieve universal coverage of CC screening in China.

In 1976, Harald Zur Hausen put forward the association between HPV and CC for the first time [8]; this encouraged the study of the pathogenesis of CC. There are over 100 genotypes of HPV which are classified into two groups according to their ability to transform epithelial cells: high risk and low risk. In the current survey, we found that 77% of women in the three northeastern provinces did not understand the link between HPV infection being a precursor for developing cervical cancer. This percentage is slightly higher than that reported by Shenzhen and Macau [9, 10], which may be related to local economic level, education base, geographic location, health awareness, and culture. Shenzhen, Macao, and other regions have a fast pace of life, and people pay more attention to their health under the prevailing conditions of high intensity and high pressure. At the same time, the understanding of HPV vaccine was similar to that of CC. Two-thirds of women surveyed obtained their information from medical institutions, which re-emphasizes the importance of medical institutions in conveying knowledge. The findings of this study are similar to those of a recent study. More people choose to believe in doctors, and the online platform also shows advantages. Therefore, a variety of publicity strategies can be combined to promote the HPV vaccination rate and promote HPV prevention and control of related diseases [11‐14]. At the time of treatment, doctors should strengthen the promotion of CC and related knowledge. Medical colleges should provide teachers and students with relevant knowledge to inform the public, and also promote mass communication through the power of the media. Schools should also introduce relevant knowledge to improve people’s understanding of CC and HPV.

Women are not only susceptible to HPV infection, the cause of CC, but are also the guardians of children. They play a decisive role in whether or not to vaccinate. Parents’ knowledge of HPV and health awareness directly affects their willingness to vaccinate their children. Therefore, it is of great significance to investigate women’s awareness of CC and HPV, and of the corresponding vaccine [5, 10]. In the population surveyed, 20% (n = 46) of women had heard of HPV vaccine. This finding is in line with a study reported in 2017 in which the rate of awareness of HPV vaccine was 17.13% [15]. The survey found that 45.6% (n = 105) of women disagreed to recommend HPV vaccine to adolescents. The reason why vaccination is not recommended for adolescents is mainly concerned with the long-term effects and side-effects of the vaccine. It has been reported in the literature that about 6–12% of parents in Europe and the USA worry that vaccination will promote premature sexual behavior among adolescents [16, 17]. In this study, 54.4% (n = 125) of women agreed to recommend HPV vaccine to adolescents, but nearly half of the women considered that the most suitable age for vaccination was over 18 years old. The American Academy of Pediatrics (AAP) recommends that HPV vaccination should be performed at 11–12 years old for both boys and girls since HPV vaccines are most effective before adolescents begin sexual activity [12]. HPV vaccines have been launched in most countries and regions of the world; more than 80 countries have listed HPV vaccines in their national vaccination program, and 30 countries or regions have listed them in their pilot vaccination program. However, China is still in a state of voluntary vaccination. In our survey, 83.9% of women hoped that HPV vaccination would be incorporated into the national immunization plan, stating that if HPV vaccination becomes routine, they would agree to their daughters receiving HPV vaccine. Therefore, China should also include HPV vaccines in national vaccination programs as soon as possible to increase the vaccination rate among adults and appropriate children, in order to reduce the trend toward a higher incidence of CC in the young.

The price of the HPV vaccines launched is about RMB1000/dose and it is recommended to use three doses. In our survey, few of the women investigated could accept such a price. The price which could be accepted by most respondents was below RMB500. Manufacturers should consider speeding up vaccine development, reducing vaccine prices to make them affordable to more people, increasing the number of vaccines, and enabling people to be vaccinated in order to greatly reduce CC incidence. In addition, the HPV vaccine should be included in the scope of medical insurance reimbursement, and the reimbursement rate should be increased as much as possible. In recent years, some provinces and cities in southern China have included it in the scope of medical insurance reimbursement, but, owing to the limited number of vaccines and large population, it is difficult to popularize each one that is suitable for women. In the procurement of vaccines, the health department has signed a procurement agreement to ensure the supply of future products and to reduce the sales price as much as possible [17]. Given the short-term listing of vaccines in mainland China, it is difficult to make an appointment. Instead, one may need to go to Hong Kong or abroad to be vaccinated, incur high costs, and may face the risk of vaccines becoming out of stock, which are reasons behind the low vaccination uptake by women in northeastern China [18].

Current HPV vaccines include prophylactic and therapeutic vaccines. Therapeutic HPV vaccines are still being investigated. Most HPV vaccines, including those launched in China, are prophylactic vaccines. There are no reports of serious adverse reactions so far [13]. However, HPV vaccines cannot prevent infections by all types of HPV. Although prophylactic HPV vaccines are essential for the primary prevention of CC, for those who have been vaccinated with HPV vaccines, CC screening is still required [2]. With the increase in the incidence of CC, it is important to improve the knowledge of CC and HPV among women [5, 19], to minimize the price of CC screening and HPV vaccines, and to include them in the scope of health insurance, so that most people have the ability to receive CC screening and to afford HPV vaccine. This would eliminate CC.

Many studies in China and abroad have shown that people’s awareness of CC, HPV, and its vaccine can effectively improve the vaccination rate of HPV [5, 6, 9], reduce the incidence of CC, and the mechanism of action, effectiveness, and safety of vaccines. Where the HPV vaccination rate is higher, the mortality rate of CC is lower. This study found that two-thirds of women’s understanding of CC in northeastern China comes from medical institutions. Therefore, effective measures to improve the level of knowledge of HPV include strengthening the publicity and education provided by medical institutions, especially in the era of network information, news websites, and social media platforms. The online medical service platform and knowledge base are developing rapidly. A professional platform should be added to disseminate relevant knowledge on a regular basis, so that people can quickly and comprehensively increase their knowledge of HPV and HPV vaccines [5, 20, 21].

At present, studies involved in disseminating knowledge of CC and HPV in northeastern China, particularly large-sample studies to identify the reasons for the low knowledge of the disease in this region, as well as providing potential solutions, are still lacking. To improve knowledge of the disease among the women of this region and increase the HPV vaccination rate, on the one hand, requires appropriate education and follow-up from medical staff, and publicity via the media or internet. On the other hand, the support of vaccine suppliers is important, for example, in developing low-price vaccines and launching corresponding policy incentives [2, 21]. In addition, factors such as family income, education level, culture, and conservative attitudes influence women’s awareness of CC in northeastern China. Finally, the strong support of the government is particularly important; measures such as increasing the number of vaccination clinics, reducing the vaccine cost, and increasing the coverage of healthcare insurance can effectively improve the popularization and application of HPV vaccine.

The survey showed that women in northeastern China had a low level of knowledge of CC, HPV infection, and HPV vaccine; 83.4% of the women lacked knowledge of the disease and had a skeptical attitude toward HPV vaccine. It is important to strengthen the knowledge of the disease and HPV vaccine, and to increase the HPV vaccination rate among the women in this region. Medical institutions are the primary channel used by the women in this region to acquire relevant information; therefore, enhancing the education and propaganda offered by medical institutions is an important avenue by which to prevent CC. Meanwhile, reducing the HPV vaccine price and increasing its coverage are crucial for improving HPV vaccination rates.