Knowledge of human papillomavirus vaccines among university students in Angola

Cervical cancer is the rst most common cancer among women in Angola and accounts for 37.6% of cancers among women in Angola. The human papillomavirus (HPV) is a causative agent of the disease. Recent advances in technology have led to the introduction of vaccines to prevent HPV infection. This study aims to assess the awareness of university students about HPV infection as a causal factor for cervical cancer and their knowledge about HPV vaccination. Assessing knowledge about vaccination among university students helps us to understand the level of awareness about it. Methods: A questionnaire-based study was carried out on 106 university students, from May 10th to July 26th, 2021. The questionnaire consisted of 10 multiple-choice questions and the results were analyzed using percentages. Results: Knowledge about HPV as a causative agent of cervical cancer was found in 84.2% of students. Awareness of the availability of the HPV vaccine was observed in 55.3%. Complete vaccination status was veried in 0% male students and 13% female students. No male students and 13 female students received incomplete vaccination. 33 men and 73 women were willing to be vaccinated with the HPV vaccine. The present study concludes that there is not a good knowledge of university students about cervical cancer and its prevention. There is also little knowledge about the HPV vaccine, meaning the availability of the vaccine, the right age group for vaccination and the recommended vaccination for men need to be improved. Vaccination status is poor among men and women because it is not on the national vaccination calendar. The desire to get vaccinated in male students was lower compared to female students. Thus, there seems to be a need to motivate male students for vaccination. Therefore, more awareness should be created about the HPV vaccine among students. The government through the Ministry of Health must incorporate the HPV vaccine in the vaccination calendar.


Introduction
Cervical cancer is the rst most common cancer among women in Angola, and the human papillomavirus (HPV) is an important causative agent of the disease [1]. We now have vaccines available to prevent HPV infection. There is a need to study the awareness of HPV vaccination and take steps to improve the use of vaccination.
Cervical cancer accounts for 37% of cancers among women in Angola. A total of 2,949 new cases of cervical cancer were diagnosed in 2018 [2]. It is considered the rst leading cause of female cancer-related deaths in Angola [2].
Human papillomavirus (HPV) infection is now a well-established cause of cervical cancer and there is growing evidence that HPV is a relevant factor in other anogenital cancers (anus, vulva, vagina and penis) as well as head and neck cancers . HPV types 16 and 18 are responsible for about 70% of all cervical cancer cases worldwide. HPV vaccines that prevent HPV 16 and 18 infections are now available and have the potential to reduce the incidence of cervical cancer and other anogenital cancers [3].
In a study conducted among Iranian women in 2013-16, the prevalence of HPV infection was 29.3% [6]. In the same study, among HPV-positive individuals, the high and low-risk HPV subtypes were found 67.2% and 52.0%, respectively [6]. A study was conducted in the rural Philippines in 2020 among the community that inferred that only 13.9% had undergone cervical cancer screening [7]. In a study conducted among Thai women in 2020, 46% of participants had insu cient knowledge about HPV infection and vaccination [8].
Vaccination is also recommended for boys as it is also implicated in penile, rectal, and oral cancer. Men also play a role in the transmission of HPV infection to women [9].
As the HPV vaccine is a recent introduction and is targeted at the 9 to 26 age group, awareness of this vaccine in the general population appears to be lower. 9-14 years is the ideal age to administer this vaccine, as it provides maximum immunogenicity of the vaccine at that age [10].
In a study conducted in Mangalore with medical students, 78.35% of students were aware of cervical cancer prevention; 82.47% knew that cervical cancer is caused by a virus; 74.22% were aware of the availability of the vaccine [11]. In a study carried out in Manipal with medical students, only 28.4% of male students knew that there is a need for vaccination in men [12]. The HPV vaccine is a more recent addition to the universal immunization schedule.
Therefore, your awareness is lower compared to other vaccines.
Assessing knowledge about vaccination among university students helps us to understand the level of awareness about it among future physicians.
Knowledge about the symptoms of cervical cancer can help with the early detection and treatment of cervical cancer. After discovering the vaccination status, he will guide us to conduct proper awareness programs and motivate students to get vaccinated.
This study was carried out with the following objectives: 1. Assess knowledge of the HPV virus as a causal factor for cervical cancer.
2. Assess knowledge about the availability of HPV vaccination.

Assess attitude towards vaccination.
4. Assess the vaccination status of university students surveyed.

Materials And Methods
A cross-sectional study was conducted on students from different universities and faculties of medicine, nursing, law, administration, psychology, engineering, and science in Angola. The inclusion criteria were students willing to participate in the study, attending the 2nd to the 4th degree of graduation, and aged between 18-26 years. Exclusion criteria were those who were unwilling to participate in the study.
A sample of 106 students was chosen (2nd to 4th students). The subjects were explained about the nature of the study. After obtaining consent, the questionnaire was sent via email. For data collection, the questionnaire was prepared using the google forms platform. The questionnaire consisted of 10 questions, of which 4 questions assessed knowledge, 4 questions assessed attitude, and 2 questions assessed practice concerning HPV infection and HPV vaccination. The questions were of the multiple-choice type, the participants were asked to choose an answer. The questions about attitude and practice were yes or no questions.
Knowledge was assessed through questions about risk factors, causal agents, cervical cancer screening methods. In the question about risk factors, 4 correct risk factors were given and the inference was made about each risk factor chosen in percentage. Likewise, the question: cancers most common among women in Angola; was rated 2 out of 4 correct answers in the options.
Questions about knowledge of vaccine availability, if the vaccine is given in health facilities; were used to assess knowledge about the HPV vaccine with a yes or no type of answer. The question about the right age group for vaccination had 1 in 4 correct answers in the options.
Attitude was assessed based on willingness to be vaccinated and to recommend the vaccine to a female relative with a yes or no type of response.
Percentages based on correct answers were calculated and compared for each question separately for male and female students.

Results
A total of 106 university students participated in the study. Among them, 33(32%) were male and 73(68%) were female. Ages ranged from 18 to 26 years old and most were 20 and 21 years old.

knowledge about cervical cancer
In a question about the most common cancers among women in Angola, 30 (29%) participants chose breast cancer, 46 (45%) participants chose cervical cancer and 30 (21%) both chose breast cancer. breast and the cervix.
* Knowledge about cervical cancer; ** knowledge about the HPV vaccine More female students compared to male students were aware of this.
Knowledge about the HPV virus as a causative agent of cervical cancer was found in 4 (12%) men and 72 (99%) women.
Among male students, 8 (24%) of the students correctly identi ed risk factors for cervical cancer such as early marriage, early childbirth, multiple sexual partners, and infections, respectively. Among female students, 39 (53%) of the students were able to correctly identify early marriage, early childbirth, multiple sexual partners, and infections, respectively, as risk factors for cervical cancer.
A question was asked about the method of screening for cervical cancer, where 3 (9%) of men and 66 (91%) of women chose Pap smear as the correct screening method.
When asked whether cervical cancer can be treated if detected early, 30 (92%) men and 70 (96%) women responded positively.
Knowledge about the HPV vaccine 59 (82%) women compared to 14 (44%) men were aware of the availability in private hospitals of the HPV vaccine for cervical cancer in 2 private hospitals.
When asked about the right age group for vaccination, 53 (72%) women compared to 7 (2%) men gave the correct answer and this association was statistically signi cant.
Only 7 (2%) men knew that the HPV vaccine could be administered to boys, while 72 (99%) women knew this fact. 33 (100%) male students and 73 (100%) female students agreed that women who have already been vaccinated need cervical cancer screening.
Among the participants, sources of knowledge and information about the HPV vaccine were found as teachings from faculties of medicine, nursing, friends, newspapers, books, the internet, and television, respectively.
Practice concerning HPV vaccination 0 (0%) of male students was fully vaccinated, while 9 (13%) of female students were fully vaccinated. In addition, it was found that 0 (0%) male students and 1 (0.73%) female students took the partial course of vaccination.

Attitude towards HPV vaccination
Among participants, 73 (100%) female students compared to 32 (99%) male students were willing to be vaccinated. Among participants, 32 (99%) men and 73 (100%) women were ready to recommend the vaccine to a female relative.

Discussion
Our study aimed to assess the knowledge and acceptability of the HPV vaccine among university students. In this study, which was carried out with 106 students from various faculties, 33 were male and 73 were female.
According to our study, 4 (12%) men and 72 (99%) women knew that the HPV virus causes cervical cancer. To compare, in a study by  in Saudi Arabia, among medical students, 45% of men and 53.2% of women were able to identify HPV infection as the cause of cervical cancer. This shows that there is a big difference in knowledge about the causal agent between the two studies with more students knowing in the present study.
In the current study, 59 (82) women and 14 (44%) men knew that the HPV vaccine is available at 2 private hospitals in Luanda. A study conducted by Pandey et al. [12] in Manipal among medical students showed that 65.7% of men and 83.1% of women were aware of the availability of the HPV vaccine.
A higher percentage of male students were aware in the current study when compared. In a study conducted by Borlu et al. [15] in Turkey, among undergraduate university students, 160 (62.5%) medical students were aware of the availability of the HPV vaccine compared to 116 (66.5%) medical students in our study.
The current study shows that 32 (99%) men and 73 (100%) women were willing to be vaccinated. In addition, 32 (92%) men and 73 (100%) women were willing to recommend the vaccine to a female relative. This indicates that there is a lack of awareness among men regarding the recommended vaccination for men. This is also re ected in the fact that only 99% of men were willing to vaccinate for themselves, compared to 99% of men willing to advise a female relative to vaccinate. In a study conducted by Fu et al. [17] among medical students in Chong-qing, China, 57.2% of men and 78.5% of women were willing to receive or advise HPV vaccination.
In the present study, none (0%) male students had received the partial course of vaccination, with 0 (0%) of the men had received the full vaccination. 9 (13%) women received full vaccination with 1 (0.73%) having received a partial course of vaccination. In a study conducted by Berenson et al. [18] In the US, among 231 medical students, 81 (66.4%) female students and 16 (14.7%) male students reported having started the vaccine. Among all participants in our study, only 14 (9.3%) of the participants had received full vaccination compared to 75 (35.2%) students with complete vaccination status, according to a study by Afonso et al. [19] in the US among 213 medical students. In the same study, partially vaccinated students were 19 (8.9%), compared to 2 (1.33%) in this study.
Regarding risk factors for cervical cancer, 8 (24%) male students and 39 (53%) female students were able to correctly identify early marriage, early childbirth, multiple sexual partners, and infections such as risk factors for cervical cancer.
The Pap smear as a screening method for cervical cancer was known by 90.1% of participants in a study by Maharajan et al. [20] in Malaysia among 305 medical students. In our study, 51 (69%) of the participants demonstrated this knowledge. This knowledge seems comparable in both studies.
When asked about the need for screening for cervical cancer after vaccination, 106 (100%) of the students responded positively in the present study. In a study conducted by Yam et al. [16] in Hong Kong, among 420 medical and non-medical students, 88 (86.3%) medical students below the 3rd year and 141 (99.3%) medical students from the 3rd year onwards have this knowledge. These data appear to be similar to our study. More studies can be carried out to advocate with the Ministry of Health for the implementation of the vaccine in the national vaccination calendar.

Conclusion
The present study concludes that there is not a good knowledge of university students about cervical cancer and its prevention. There is also little knowledge about the HPV vaccine, meaning the availability of the vaccine, the right age group for vaccination and the recommended vaccination for men need to be improved. Vaccination status is poor among men and women because it is not on the national vaccination calendar. The desire to get vaccinated in male students was lower compared to female students. Thus, there seems to be a need to motivate male students for vaccination. Therefore, more awareness should be created about the HPV vaccine among students. The government through the Ministry of Health must incorporate the HPV vaccine in the vaccination calendar.