Awareness of human papillomavirus among women attending a well woman clinic.

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.

Human papillomavirus (HPV) is widely acknowledged to be the most prevalent sexually transmitted infection (STI) in the United States and elsewhere. High risk types of HPV are a necessary though not sufficient cause of the vast majority of cervical cancers. In the United States, HPV testing is recommended for the triage of women with borderline smear results. A similar system is being considered in the United Kingdom, and HPV testing in primary screening has also been suggested.

Studies in the United States have found low awareness of HPV among women in university and healthcare settings. In the United Kingdom, 70% of female university employees surveyed had never heard of the virus and in a representative population sample, fewer than 1% recalled HPV as a risk factor for cervical cancer (unpublished data).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 cancer and smear results which mention “wart virus” are poorly understood.

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.

Table 1

Characteristics of the whole sample (n=1032) and women who were aware (n=316) and unaware (n=716) of HPV, with χ2 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)
	%	No	%	No	%	No	Difference between groups χ2 [df] (p)	Odds ratio of having hear of HPV [95% CI]
*Herpes simplex, Trichomonas vaginalis, chlamydia, gonorrhoea, anaerobic vaginosis, pelvic inflammatory disease, non-specific urethritis.
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

Measures

Knowledge of HPV was measured using a series of questions similar to those used in other studies. 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).

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

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, 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. 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 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, 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.