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Keywords:

  • attitudes;
  • cervical cancer;
  • human papillomavirus;
  • intentions;
  • knowledge;
  • nurses;
  • prevention;
  • vaccination

Abstract

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. Introduction
  5. Background
  6. The study
  7. Results
  8. Discussion
  9. Conclusion
  10. Acknowledgement
  11. Funding
  12. Author contributions
  13. References

Title. Cervical cancer prevention by vaccination: nurses’ knowledge, attitudes and intentions.

Aim.  This paper is a report of a survey: (1) to document nurses’ knowledge, attitudes and information needs regarding human papillomavirus prevention and (2) to determine factors associated with their willingness to recommend human papillomavirus vaccines.

Background.  Persistent infection with human papillomavirus has been causally linked to cervical cancer. Two human papillomavirus vaccines have recently been approved for use in more than 65 countries. Nurses’ level of support for the prevention of human papillomavirus related diseases by vaccination has not been researched.

Methods.  A survey was conducted in 2007. Self-administered questionnaires were mailed to 1799 randomly selected nurses. Descriptive statistics were generated for all variables. Multivariable logistic regression models were estimated to determine variables associated with the willingness to recommend human papillomavirus vaccines.

Results.  A total of 946 questionnaires were analyzed and showed that: 97% of nurses perceived routinely recommended vaccines as very useful; 93% would support human papillomavirus vaccination if it is publicly funded; 85% would recommend human papillomavirus vaccines to their patients; 33%, 46% and 61% expect the vaccination to permit screening to begin later in life, reduction of the frequency of screening, and reduction of the number of postscreening interventions, respectively. Respondents’ knowledge score was 3·8 out of 7. Several modifiable factors, including knowledge, perceived self-efficacy, and societal and colleagues support were associated with willingness to recommend vaccines.

Conclusion.  Most nurses’ support human papillomavirus vaccination, but their active involvement should not be taken for granted. Targeted educational efforts are needed to ensure nurses’ involvement in the prevention of human papillomavirus-related diseases.


What is already known about this topic

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. Introduction
  5. Background
  6. The study
  7. Results
  8. Discussion
  9. Conclusion
  10. Acknowledgement
  11. Funding
  12. Author contributions
  13. References
  • • 
    Human papillomavirus is the main causal factor for cervical cancer and genital warts.
  • • 
    While currently available vaccines offer considerable potential to decrease the burden of human papillomavirus-related diseases, some concerns have been raised about the pace of vaccine adoption.
  • • 
    The general public, parents and physicians have important knowledge gaps but overall show high support of human papillomavirus vaccination.

What this paper adds

  • • 
    Most nurses support vaccination against human papillomavirus and are ready to recommend it to patients.
  • • 
    Nurses have heterogeneous levels of knowledge on human papillomavirus infection and virtually all would like to receive more information about it.

Implications for practice and/or policy

  • • 
    Addressing misunderstood issues in future educational materials would facilitate nurses’ understanding of the rationale of human papillomavirus vaccination and regular screening for cervical cancer.
  • • 
    Fostering general positive attitudes and societal/professional support of vaccination and delivering more evidence-based information on human papillomavirus infection and its prevention would facilitate nurses’ involvement in new immunization programmes.

Introduction

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. Introduction
  5. Background
  6. The study
  7. Results
  8. Discussion
  9. Conclusion
  10. Acknowledgement
  11. Funding
  12. Author contributions
  13. References

The use of screening for cervical precancerous lesions significantly reduced the incidence of cervical cancer. Despite this success, the imperfect sensitivity of cytology testing is estimated to be responsible for 30% of all cervical cancers, and provider error in follow up of abnormal results accounts for another 10% (Saslow et al. 2007). Moreover, screening programmes’ high cost and logistic complexity have limited their use to resource-rich countries. Worldwide, cervical cancer continues to be the second most common cancer in women after breast cancer (Parkin & Bray 2006).

Human papillomavirus (HPV) is now commonly recognized as the primary causal factor in the development of cervical disease and cancer (Clifford et al. 2005, Schiffman et al. 2005). Women with persistent HPV infection are in excess of 300 times more likely than HPV-negative women to develop high-grade precancerous cervical disease (Bory et al. 2002). More than 50% of sexually active women are exposed to at least one HPV type in their lifetime (Baseman & Koutsky 2005, Keam & Harper 2008). Because oncogenic HPV infection is necessary for the development of cervical cancer, prophylactic vaccines are likely to be of value as a primary prevention strategy (Keam & Harper 2008).

Two HPV vaccines have recently been approved for clinical use in more than 65 countries. These vaccines are more efficacious when given to females before the onset of sexual activity. While currently available HPV vaccines offer considerable potential to decrease the burden of HPV-related diseases, they do not protect against all types of the virus and, as with other new vaccines, the duration of protection is still to be determined.

Background

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. Introduction
  5. Background
  6. The study
  7. Results
  8. Discussion
  9. Conclusion
  10. Acknowledgement
  11. Funding
  12. Author contributions
  13. References

Despite the demonstrated high clinical effectiveness of HPV vaccines in the short- and mid-term, and the commonly-recognized need for primary prevention of infection, some concerns have been raised about the pace of HPV vaccine adoption (Gulli 2007, Lippman et al. 2007).

It is known that acceptability and support by healthcare professionals is an important factor in the implementation of new vaccination programmes (Erickson et al. 2005, Kimman et al. 2006).

Earlier studies clearly indicate a high level of public interest in HPV vaccination, despite overall little knowledge about this infection and related diseases (Hoover et al. 2000, Davis et al. 2004, Olshen et al. 2005, Zimet 2005, Brabin et al. 2006, Dempsey et al. 2006, Friedman & Shepeard 2008, Gonik 2006). They also confirm that one of the main predictors of vaccine acceptance is the endorsement of vaccination by healthcare professionals.

Empirical research with physicians suggests that the majority of paediatricians, obstetrician–gynaecologists and family physicians are willing to recommend HPV vaccines. Among the most notable predictors of intention to recommend the vaccination are the approval of vaccination by their professional organization and higher level of knowledge on HPV infection and its consequences. Findings also show that healthcare professionals will be more likely to recommend the HPV vaccination to girls than to boys and to older rather than younger adolescents (Mays & Zimet 2004, Raley et al. 2004, Kahn et al. 2005, Riedesel et al. 2005). For example, Raley et al. (2004) found that obstetrician–gynaecologists were more comfortable to vaccinate 17-year-old than 13-year-old girls. Several studies have shown relatively low levels of knowledge about HPV infection and its prevention in some healthcare professionals (Kahn et al. 2005, Riedesel et al. 2005). However, all these studies were done before HPV vaccines approval for clinical use.

A few studies with physicians since the approval of the HPV vaccines in 2006–2007 continue to show a high support of vaccination, but also a relatively low level of knowledge about HPV infection and its prevention in some clinicians (Duval et al. 2007, Esposito et al. 2007).

The only recent study of nurses’ knowledge, attitudes and practices vis-à-vis cervical cancer and HPV infection prevention was done in nurses working in Sringarid University Hospital in Northeast Thailand. In this study, 133 nurses responded to a self-administered questionnaire. The researchers concluded that nurses have a moderate level of knowledge about cervical cancer and HPV, but that there are still some major misunderstandings (Nganwai et al. 2008).

The need for more information about healthcare providers’ beliefs, actual knowledge and wishes for information on HPV has been repeatedly addressed (Zimet et al. 2006, Henderson et al. 2007, Howard et al. 2007). We undertook the study reported in this paper in the context of: (1) implementation of new publicly-funded HPV immunization programmes in most industrialized countries, (2) several concerns raised about these programmes and (3) lack of information about the level of support and the intentions of nurses regarding HPV vaccination. The choice of nurses was based on their decisive role in the promotion and realization of immunization programmes, as well as their known influence on patients’ decisions to receive the vaccine (Honish et al. 2002, Koch et al. 2005).

The study

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. Introduction
  5. Background
  6. The study
  7. Results
  8. Discussion
  9. Conclusion
  10. Acknowledgement
  11. Funding
  12. Author contributions
  13. References

Aims

The aims of this survey were: (1) to document nurses’ knowledge, attitudes and information needs about HPV prevention and (2) to determine the factors associated with their willingness to recommend HPV vaccines.

Design

The survey was conducted in 2007 in four Canadian provinces: Nova Scotia (NS), Quebec (QC), Ontario (ON) and British Columbia (BC). These provinces cover nearly 80% of the Canadian population. The survey was set up as a multi-centre study, with each province being an autonomous project unit with a common protocol and questionnaire. This anonymous postal survey followed the general techniques described by Dillman (2000). The methods used to document the attitudes, knowledge and practices of Canadian physicians on the same subject (Duval et al. 2007) were adapted for Canadian nurses. The guidelines published by the Canadian Association for Immunization Research and Evaluation (CAIRE) were followed (Halperin et al. 2005).

Participants

In Canada, there is no national registry of nurses for the entire country. The provincial nursing associations were approached, and at the request of the research team they randomly selected 250 practising nurses from their lists. Each provincial research team had the option to increase their sample size. Two provinces (NS, BC) increased their sample size to 898 and 401 respectively using the same random selection procedure as before. This gave a total sample of 1799 nurses. The information available in nurses associations’ databases varied across provinces. Nurses most likely to provide immunization services (community health centres, hospitals, private offices) were included in the survey population, whereas those working in emergency, surgery, elder care or long-term care were not included. This information was not available in NS and the questionnaire had to be sent to a random sample of all nurses.

Data collection

Survey Instruments

The Systems Model of Clinical Preventive Care, which considers the healthcare professional, the patient and the many factors which influence each, was used to develop the questionnaire (Walsh & McPhee 1992). This model was chosen because it takes into consideration healthcare professional predisposing factors (health beliefs and attitudes), enabling factors (knowledge, skills and resources), and reinforcing factors (professional and social support). Additional factors examined include healthcare system organizational factors (such as access), preventive activity factors (features of healthcare professional practice), and situational factors (external cues to action). The same questionnaire was used in all provinces but other documents such as letters of support and consents varied slightly, mostly because of requirements of the different ethical review boards. The questionnaire contained mostly closed-ended questions (the questionnaire is available on request).

Survey procedures

The survey documents were sent by mail with a separate return postcard to facilitate their anonymous return and to identify non-respondents to whom subsequent reminders could be sent. Three other mailings were sent to non-respondents only. At the time of the survey, one HPV vaccine (Gardasil) was approved in Canada for women aged 9–26 years.

Ethical considerations

The survey was approved by ethical review boards at each of the four study sites. All potential participants were informed of the purpose of the survey, that their participation was purely voluntary, and that confidentiality would be maintained. Willingness to complete the questionnaire was taken as consent to participate. No financial or material incentive was used.

Data analysis

Descriptive statistics were generated for all variables. For knowledge items, a ‘True–False–Not Sure’ scale was used. One point was given for each correct answer. For items measuring opinions, attitudes, perceived professional and societal support/barriers and perceived benefit from vaccination, a 4-point Likert scale ranging from ‘strongly disagree’ to ‘strongly agree’ was used. For the final analysis the responses were dichotomized into ‘strongly and somewhat agree’ vs. ‘strongly and somewhat disagree’. For preferred sources of information and intention items, the choice of answers ranged from ‘not at all likely’ to ‘very likely’. Missing answers were excluded from the analysis. Proportions were compared using the Chi-square test. Fisher’s exact test was used when ≥33% of the expected values in the cells of the contingency tables were below 5. Statistical significance was assessed using two-tailed tests with an α error level of 0·05. Multivariable logistic regression models were used to determine which variables included in the Systems Model of Clinical Preventive Care were independently associated with willingness to recommend HPV vaccination. Variables associated in the univariate analysis with willingness to recommend HPV vaccination at P < 0·20 were entered into regression models using a stepwise selection technique. Collinearity was checked and the adequacy of the model was evaluated using Hosmer and Lemeshow’s test. Analyses were conducted with sas version 9.1 (SAS Institute Inc., Cary, NC, USA).

Validity and reliability

The questionnaire was validated using a two-stage process: (1) interviews and group discussions with HPV experts and (2) group discussions and questionnaire validation with 18 nurses at two study sites. Questionnaire reliability was assessed in our previous 2006 surveys with paediatricians, family physicians and obstetricians–gynaecologists (Duval et al. 2007). Only four out of 77 items of the primary questionnaire were modified for the nurses’ survey.

Results

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. Introduction
  5. Background
  6. The study
  7. Results
  8. Discussion
  9. Conclusion
  10. Acknowledgement
  11. Funding
  12. Author contributions
  13. References

Respondent characteristics

A total of 946 questionnaires were analyzed. The response rate and characteristics for each province’s sample are presented in Table 1. The mean participation rate was 53%, varying from 38% in NS to 86% in QC. More than two thirds (68%) of respondents were involved in vaccine administration at their workplace, and more than half (58%) had at least 20 years of practice.

Table 1.   Participation and general characteristics of respondents
 Nova ScotiaQuebecOntarioBritish ColumbiaAll
  1. Two questionnaires were eliminated because of missing pages.

Questionnaires mailed8982502504011799
Questionnaires received339214160235948
Response rate38%86%64%59%53%
Administer vaccines55%71%64%87%68%
Clientele mostly children and teenagers19%48%44%49%37%
Years of practice: >20 years72%53%48%50%58%

Attitudes towards vaccination in general and willingness to recommend HPV vaccination

Ninety-seven percent of nurses perceived vaccines routinely recommended by the National Advisory Committee as very useful. A higher proportion of nurses who administered vaccines at their workplace were willing to recommend HPV vaccination when compared with nurses who did not administer vaccines, 90% vs. 76% (Chi-square test P-value < 0·0001). Considerable heterogeneity was observed in the proportions of nurses who showed willingness to recommend HPV vaccination in four provinces (Chi-square test P-value = 0·008) (Table 2).

Table 2.   General attitudes towards vaccination and intention to recommend human papillomavirus (HPV) vaccination (% of strongly and somewhat agree responses)
ItemAll nursesNurses who administer vaccinesProvinceP-value*
YesNoP-value*Nova ScotiaQuebecOntarioBritish Columbia
  1. *Chi-square test P-value.

In general, recommended vaccines are very useful9797970·75979698980·83
I will recommend HPV vaccines*859076<0·0001859178860·008

Knowledge

The proportion of correct answers to knowledge questions varied from 11% to 77% (Table 3). Questions about the role of HPV in cervical cancer and anogenital warts development were correctly answered by 74–77% of respondents. However, only 11% knew that cervical smear tests have a sensitivity of <75%, and only 19% knew that anogenital warts are not cervical cancer precursors. The overall score for knowledge items was 3·8 out of 7. Ninety-three percent of nurses who had a higher than overall score for knowledge questions were willing to recommend HPV vaccines vs. 76% of those who responded correctly to less than four out of seven knowledge questions (Chi-square test P-value < 0·0001). Forty-one percent of respondents self-estimated the information they had received on HPV vaccines as somewhat sufficient or sufficient to their needs.

Table 3.   Nurses’ knowledge about human papillomavirus (HPV) infection and its prevention
ItemNo. of responsesCorrect answers
n%
  1. The correct answer was ‘True’ for all but * items; the difference between the total number of questionnaires analyzed (946) and the number of responses to a given item is because of missing answers.

HPV is the most common sexually transmitted infection (STI)93056761
More than 70% of the population is infected with the HPV at some point in their life94258462
Cervical cancer is caused by a persistent HPV infection93969574
Conventional screening Pap tests have a sensitivity of more than 75%*93910311
There are specific HPV genotypes that cause cervical cancer93672177
There are specific HPV genotypes responsible for most anogenital warts94372176
Anogenital warts induced by HPV are cervical cancer precursors*93117719
Self-estimated knowledge on HPV vaccines929  
 Somewhat sufficient or Sufficient385 41
 Not sufficient544 59

Opinions on key HPV vaccination programme components

Although 85% of all respondents would recommend HPV vaccination, support varied considerably according to source of funding, knowledge and involvement in vaccine administration (Table 4). A higher proportion would support HPV vaccination if it was publicly funded (93% vs. 62% if clients had to pay; Chi-square test P-value < 0·0001). Nurses also thought that parents would more readily accept HPV vaccination for their children <14 years of age if it was publicly funded (89% vs. 20% if parents had to pay for the vaccine; Chi-square test P-value < 0·0001) and would prefer the HPV vaccination to be given at school (86%).

Table 4.   Nurses’ opinions on key components of human papillomavirus (HPV) vaccination programmes (%)
StatementSomewhat or strongly agree
All nursesNurses who correctly responded toNurses who administer vaccines
≥4 knowledge questions (n = 573)≥4 knowledge questions (n = 573)P-value* Yes (n = 640) No (n = 297)P-value*
  1. *Chi-square test P-value

I would support HPV vaccination…
 If it is publicly funded9395920·1094930·61
 Even if clients have to pay for the vaccine (cost approx. 150$ per dose)626753<0·000164570·03
In my opinion, most nurses will recommend HPV vaccination …
 If it is publicly funded9697950·0997950·24
 If clients have to pay for the vaccine6770600·0368630·11
In my opinion, most parents will accept HPV vaccination for their children less than 14 years of age …
 If it is publicly funded899384<0·000191850·004
 If they have to pay for the vaccine2020200·8420210·70
HPV vaccines should be given to…
 Girls before they become sexually active919486<0·000193860·0009
 Boys before they become sexually active7780730·00380710·003
 All sexually active females8281830·4282830·53
 All sexually active males7071690·5070690·76
 Only to individuals who have many sexual partners 2118240·0420220·55
An HPV vaccination programme would eventually permit the…
 Beginning of screening later in life3333330·8133330·95
 Reduction of the frequency of screening interventions in vaccinated females4646460·8445480·45
 Reduction of the number of postscreening follow-up interventions6163560·0263550·03
 Discontinuation of screening6570·07580·12
The best age for a universal HPV immunization programme would be…
 <14 years717960<0·00017662<0·0001
 14–17 years272037 2335 
 ≥18 years212 13 

Ninety-one percent of respondents said that the HPV vaccine should be given to girls before they became sexually active. A large proportion (82%) also believed that HPV vaccines should be given to all sexually active females. The majority (94%) believed screening for cervical cancer should be continued in vaccinated females. However, a relatively high proportion expected that vaccination would permit screening to begin later in life (32%), reduction of the frequency of screening interventions in vaccinated women (46%), and reduction of the number of postscreening follow-up interventions (61%).

The best age for a universal HPV immunization programme was under 14 years for 71% of respondents, 14–17 years for 27% and ≥18 years for 2%. Nurses who had a lower than average knowledge score were more likely to think that the best age for a universal immunization would be 14–17 years (Table 4).

Predictors of HPV vaccine recommendation

In multivariate analysis several predisposing, enabling, reinforcing, system/organizational, and test/preventive activity factors were independently associated with willingness to recommend HPV vaccines (Table 5). Several of these were modifiable factors, including perceived self-efficacy in counselling about HPV vaccination, knowledge about HPV infection and its prevention, perceived professional and societal support, and perceived benefit from vaccination.

Table 5.   Predictors of willingness to recommend the human papillomavirus (HPV) vaccines
VariableItemOR95%CI*P-value
  1. logistic regression model adjusted for province; OR, Odds Ratio; *95% confidence interval.

Predisposing factors
Attitudes toward vaccination and self efficacyPatients’ compliance with the counsel regarding HPV vaccination
 Compliance4·9  
 Non-compliance12·4–9·8<0·0001
Enabling factorsSelf-estimated sufficiency of information received
  Sufficient or Somewhat sufficient2·8  
  Not sufficient11·7–4·8<0·0001
 Correct answers to knowledge questions
  ≥4 out of 71·9  
  <4 out of 711·2–3·10·005
Reinforcing factors
Societal supportParents’ acceptance of HPV vaccination for their children
 Yes3·8  
 No12·1–6·6<0·0001
Professional supportNurses’ support of HPV vaccination
 Yes3·01·2–7·80·02
 No1  
System/Organizational factors
Ready availabilityGroup mostly working with
 Children & Teenagers2·21·2–3·80·007
 Adults & Mixed1  
Access to vaccinationProvide information about vaccines at his workplace
 Yes3·11·8–5·3<0·0001
 No1  
Test/Preventive activity factors
Efficiency when applied to target populationThe best age for universal immunization
 <14 years2·71·7–4·3<0·0001
 >14 years1  
Importance of action/perceived benefitThe beginning of screening later in life
 Yes1·91·2–3·30·008
 No1  

Topics to be included in educational materials and preferred sources of information

More than nine out of ten respondents agreed the following topics should be included in training materials and clinical decision support tools: cervical cancer screening and management of cervical smear test results (93%), HPV counselling (95%); psycho-social issues related to HPV (95%), vaccine safety profile (95%); vaccine efficacy and effectiveness (97%). They would look for information about HPV vaccines in Canadian/Provincial guidelines (87%), the internet (76%), scientific literature (73%), information from pharmaceutical companies (68%) and conferences/colloquiums (67%).

Discussion

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. Introduction
  5. Background
  6. The study
  7. Results
  8. Discussion
  9. Conclusion
  10. Acknowledgement
  11. Funding
  12. Author contributions
  13. References

Study limitations

This study had several limitations. First, our sample may not be representative of all nurses involved in immunization. The master lists varied among provinces according to available information. As a consequence, the response rate was relatively low in some provinces where it was sent to a random sample of all nurses, and much higher where it was possible to identify more precisely the intended audience of nurses potentially involved in immunization. However, the overall response rate of 53% remains satisfactory for a postal survey of healthcare professionals (Raley et al. 2004, Kahn et al. 2005). It is also reassuring that despite interprovincial variations in survey respondents, general characteristics of the pattern of responses were quite similar across all provinces. Second, this survey was conducted after HPV vaccine approval in Canada but before provinces or territories had initiated extensive education programmes for nurses on the new publicly-funded HPV vaccination programme. Considering the large media visibility and the major professional education efforts under way, both by manufacturers and public health authorities, this picture may change quickly. On the other hand, even if knowledge increases, attitudes might take a much longer time to modify (Yassi et al. 1994, Prislin et al. 2002, Comité sur l’immunisation du Québec 2005).

To our knowledge, this is the first survey assessing nurses’ attitudes, knowledge and educational needs on HPV infection and its prevention by vaccination in a country with an established cervical cancer screening programme. The survey demonstrates that a large majority of nurses are in favour of HPV vaccination. Overall, more than nine out of ten would support HPV vaccination if it were publicly-funded. However, the proportion of nurses who would support HPV vaccination dropped by almost 1/3 if clients had to pay for the vaccine. These results are different from those reported in our previous study with Canadian obstetricians, family physicians and paediatricians (Duval et al. 2007). The need for patients to pay for the vaccine decreased the intention of physicians to recommend HPV vaccination by only 3–4%. For nurses, public funding also appears to be an important prerequisite for the support of their colleagues and, foremost, for the acceptance of parents immunizing their children.

The findings were mixed regarding the population who should be immunized. While the great majority would support the immunization of girls before they become sexually active, more than four out of five nurses would also immunize all sexually active women. On the other hand, just over one fifth would vaccinate only those who have many sexual partners. This goes somewhat against the evidence to date that HPV infection is acquired early in sexual life, and the understanding that vaccines become less effective if a person has had many partners (Bosch & Harper 2006, Wright et al. 2006, Baden et al. 2007). Our survey results also show that nurses with lower knowledge scores, those who self-estimated the information they received on HPV vaccines as insufficient, and those who did not administer vaccines understood less well the need for HPV vaccine administration to girls before they become sexually active. Higher levels of knowledge also seem to help in understanding the need for universal rather than selective vaccination (i.e. vaccine administration only to individuals who have many sexual partners). However, overall our results show a better understanding of the need to vaccinate young girls than that in the Raley et al. (2004) study.

There was also some support for immunizing males, which may become a controversial issue since vaccination of males is not currently recommended by the National Advisory Committee on Immunization (Dobson et al. 2007). Male vaccination is not publicly funded in any country, mainly because of the uncertain impact of such a vaccination and the astronomic cost estimated at about 450,000$ per quality adjusted life year (Taira 2004).

It is expected that HPV immunization programmes will have an impact on cervical cancer screening activities and would require changes in current screening guidelines (Franco et al. 2006). Our results showed that there is some support by nurses for changes. It is also reassuring to note that <10% would agree with the discontinuation of screening. They also show that most nurses understood the limits of the HPV vaccines presently available and the need for an optimal synergy between screening and immunization.

The survey also showed that some nurses lack knowledge about HPV infection and its prevention. Furthermore, only four out of ten considered their knowledge on HPV vaccine to be somewhat sufficient or sufficient. It is relevant to note that a large majority grossly overestimated the sensitivity of the cervical smear test, which would tend to place too much reliance on screening. As in the Henderson et al. (2007) study with United States clinicians, many nurses wrongly thought that genital warts are cancer precursors. This misunderstanding merits special attention because very traumatic and incorrect messages could be sent to patients. In our opinion, the fact that virtually all respondents mentioned that they would like training materials to include psychosocial and HPV counselling topics shows that many nurses do not have enough confidence in addressing these issues with patients.

The results of multivariate analysis were congruent with those previously obtained with North American clinicians (Mays & Zimet 2004, Raley et al. 2004, Kahn et al. 2005, Riedesel et al. 2005, Duval et al. 2007) and highlight that the generally positive attitudes of nurses towards vaccination, their knowledge about HPV infection and its prevention, and their ability to counsel patients on HPV are the main factors independently associated with the willingness to recommend HPV vaccines. The results also demonstrate the importance for nurses of perceived societal support and peer norms when recommending a new vaccine.

It is important to mention that a higher level of knowledge about HPV infection and its prevention statistically significantly increases nurses’ willingness to recommend the vaccination and helps them to understand the peculiarities of HPV vaccination and the need to combine vaccination with the screening for precancerous lesions.

Conclusion

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. Introduction
  5. Background
  6. The study
  7. Results
  8. Discussion
  9. Conclusion
  10. Acknowledgement
  11. Funding
  12. Author contributions
  13. References

The observed relationship between (1) perceived usefulness of vaccines in general, (2) perceived societal and colleagues support of HPV vaccination, (3) the level of knowledge on HPV and the willingness of nurses to recommend the vaccination highlight how their support of new immunization programmes could be improved. Addressing misunderstood issues in future educational materials would facilitate nurses’ understanding of the rationales of HPV vaccination and regular screening for cervical cancer. More research is needed into nurses’ beliefs, intentions and information needs when new prevention programmes are implemented.

Acknowledgement

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. Introduction
  5. Background
  6. The study
  7. Results
  8. Discussion
  9. Conclusion
  10. Acknowledgement
  11. Funding
  12. Author contributions
  13. References

We are grateful to the survey participants and provincial nurses’ associations of Nova Scotia, Quebec, Ontario and British Columbia for their collaboration to this survey, and to Kate O’Connor, Sophie Auger, Charlene Beynon, Patricia Sealy, and Darlene Baxendale whose active involvement we greatly appreciate. We express our gratitude to GlaxoSmithKline for the complete latitude we had in doing this research and to the Canadian Association for Immunization Research and Evaluation (CAIRE) Human Papillomavirus Psychosocial Research Group Members: Simon Dobson, Deborah Money, Shelly McNeil and Ian Gemmill for their methodological support. Sadly, Bernard Duval died while this paper was in preparation.

Author contributions

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. Introduction
  5. Background
  6. The study
  7. Results
  8. Discussion
  9. Conclusion
  10. Acknowledgement
  11. Funding
  12. Author contributions
  13. References

BD, VG, NB, KP, BH, MAS, CS, MO, ED & FL were responsible for the study conception and design. VG, NB, KP, BH & MAS performed the data collection. BD, VG & MO performed the data analysis. BD & VG were responsible for the drafting of the manuscript. BD, NB, KP, BH, MAS, CS, ED & FL made critical revisions to the paper for important intellectual content. VG & MO provided statistical expertise. BD obtained funding. MO & FL provided administrative, technical or material support. BD, VG & FL supervised the study.

References

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. Introduction
  5. Background
  6. The study
  7. Results
  8. Discussion
  9. Conclusion
  10. Acknowledgement
  11. Funding
  12. Author contributions
  13. References
  • Baden L.R., Curfman G.D., Morrissey S. & Drazen J.M. (2007) Human papillomavirus vaccine--opportunity and challenge. The New England Journal of Medicine 356(19), 19901991.
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