Effect of intervention in increasing knowledge and awareness of Human Papilloma Virus (HPV) infection and HPV vaccination among graduate students in a private university, Kedah state, Malaysia

Abstract

Introduction Human Papilloma Virus (HPV) is the causative agent of several skin and mucosal diseases, including virtually all cases of the world's second most common female malignancy, cervical cancer, and genital warts, the most common disease occurring in sexually active population. 1 The early history of HPV infection and its relation to cervical carcinogenesis have been observed in many studies. 2 However, cervical cancer development is a long process lasting 15-20 years. 3 It implies, the persistence of infection with high-risk HPV type in a minority of infected women, leading to pre-cancerous lesions (3-5 years), and eventual development of invasive cancer in the long term (>10 years). 3,4 HPV is usually transmitted through direct skin-to-skin contact, most often during penetrative genital contact (vaginal or anal sex). 5 Other non-genital contact without penetration (oral-genital, manual-genital, and genital-genital contact) can also lead to HPV infection but less common than sexual intercourse. 6 Sexual behaviour is the most constant predictor and most importantly, the number of sex partners is proportionately linked to the risk of HPV infection. 7-9 For women, the sexual activity of their partner(s) is also important for HPV acquisition. Among adolescent and college female's students, the HPV risk is increased if a woman's partner had or currently has other partners. HPV infections are also common in men who have sex with men (gay) and women who have sex with women (lesbian). The development of HPV vaccine is a landmark in the history of immunisation, since this is one among the first vaccine primarily directed and perceived as anti-cancer vaccine. The HPV vaccine has the potential to complement secondary prevention and control cervical cancer morbidity and mortality worldwide if vaccinated before sex initiation in females. 10 The two presently available (quadrivalent and bivalent) and the latest nanovalent HPV vaccines have proven their efficacy in the prevention of pre-cancerous lesions (Cervical Intraepithelial Neoplasia-CIN), and can exert their maximum MOJ Bioequiv Availab. Abstract Background: It is imperative to establish concrete evidence regarding the effect of educational intervention in improving individuals' knowledge towards human papilloma virus (HPV) infection and vaccination initiatives among the unvaccinated age eligible adult population in Malaysia. The outcome measures were to assess the level of knowledge regarding HPV infection and vaccination among graduate students from a private university, Malaysia; to find the association between knowledge score and socio-demographic variables and to estimate the effect of educational intervention (pamphlet) tool at pre-and post-intervention studies.

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Introduction
Human Papilloma Virus (HPV) is the causative agent of several
skin and mucosal diseases, including virtually all cases of the
world’s second most common female malignancy, cervical cancer,
and genital warts, the most common disease occurring in sexually
active population.1 The early history of HPV infection and its
relation to cervical carcinogenesis have been observed in many
studies.2 However, cervical cancer development is a long process
lasting 15–20 years.3 It implies, the persistence of infection with
high-risk HPV type in a minority of infected women, leading to pre-
cancerous lesions (3–5 years), and eventual development of invasive
cancer in the long term (>10 years).3,4
HPV is usually transmitted through direct skin-to-skin contact,
most often during penetrative genital contact (vaginal or anal sex).5
Other non-genital contact without penetration (oral-genital, manual-
genital, and genital-genital contact) can also lead to HPV infection
but less common than sexual intercourse.6 Sexual behaviour is the
most constant predictor and most importantly, the number of sex
partners is proportionately linked to the risk of HPV infection.7–9 For
women, the sexual activity of their partner(s) is also important for
HPV acquisition. Among adolescent and college female’s students,
the HPV risk is increased if a woman’s partner had or currently has
other partners. HPV infections are also common in men who have
sex with men (gay) and women who have sex with women (lesbian).
The development of HPV vaccine is a landmark in the history
of immunisation, since this is one among the rst vaccine primarily
directed and perceived as anti-cancer vaccine. The HPV vaccine has
the potential to complement secondary prevention and control cervical
cancer morbidity and mortality worldwide if vaccinated before sex
initiation in females.10 The two presently available (quadrivalent
and bivalent) and the latest nanovalent HPV vaccines have proven
their efcacy in the prevention of pre-cancerous lesions (Cervical
Intraepithelial Neoplasia–CIN), and can exert their maximum
MOJ Bioequiv Availab. 2018;5(4):187‒193. 187
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Effect of intervention in increasing knowledge and
awareness of Human Papilloma Virus (HPV) infection
and HPV vaccination among graduate students in a
private university, Kedah state, Malaysia
Volume 5 Issue 4 - 2018
Abdul Nazer Ali,1 Ng Yen Ping,1 Sunil K
Prajapati,1 Lim Cheng Pheng,1 Mohd Zahid
Iqbal,1 Nazer Zulkar Ahmed2
1Faculty of Pharmacy, AIMST University, Malaysia
2Pzer Health Care India Pvt Ltd, India
Correspondence: Abdul Nazer Ali, Faculty of Pharmacy,
AIMST University, Semeling-08100, Bedong, Kedah Darul Aman,
Malaysia, Tel 0060103730262, Email abdul.nazerali16@gmail.com
Received: July 18, 2018 | Published: July 30, 2018
Abstract
Background: It is imperative to establish concrete evidence regarding the effect
of educational intervention in improving individuals’ knowledge towards human
papilloma virus (HPV) infection and vaccination initiatives among the unvaccinated
age eligible adult population in Malaysia. The outcome measures were to assess the
level of knowledge regarding HPV infection and vaccination among graduate students
from a private university, Malaysia; to find the association between knowledge score
and socio-demographic variables and to estimate the effect of educational intervention
(pamphlet) tool at pre- and post-intervention studies.
Method: A longitudinal study, designed for repeated measures using pre-validated
questionnaires, with pre- and post-test (0 and 1 month) among graduate students in
Malaysia. The results from both phases were compared using McNemar’s test and
Wilcoxon signed rank test for precise differences in knowledge scores.
Results: The response rate was 58.8% (470/800), participants had a poor percentage
and median knowledge score in pre-test, 45% [7(6), ranging 0 to 15] with age, course of
study, year of study and location (p<.01). A significant increase in scores was observed
post-intervention test, 83% [13(2), ranging 7 to 15] with course of study (p<.01).
An exact McNemar’s test determined that there was a strong statistically significant
difference in the proportion of knowledge scores between pre- and post-test, p<.01.
Wilcoxon test (N=470) confirmed a strong significant difference in knowledge score
between both phases of study (Z=17.2, N=470, p<.001).
Conclusion: The findings reveal, even healthcare graduate students have poor
knowledge regarding the various issue of HPV, which queries the status of general
public with less literacy. It is strongly recommended that more exposures should be
given to the general public to enrich their knowledge for vaccine acceptance and
periodic Pap screening for females at risk.
Keywords: educational Intervention, healthcare graduate students, HPV infection,
HPV vaccination, knowledge, pamphlet
MOJ Bioequivalence & Bioavailability
Research Article Open Access

Effect of intervention in increasing knowledge and awareness of Human Papilloma Virus (HPV) infection
and HPV vaccination among graduate students in a private university, Kedah state, Malaysia 188
Copyright:
©2018 Ali et al.
Citation: Ali AN, Ping NY, Prajapati SK. Effect of intervention in increasing knowledge and awareness of Human Papilloma Virus (HPV) infection and HPV
vaccination among graduate students in a private university, Kedah state, Malaysia. MOJ Bioequiv Availab. 2018;5(4):187‒193. DOI: 10.15406/mojbb.2018.05.00101
efciency if used at pre-adolescent age.11 However, they need to
extend their protective effect for many years if a substantial impact on
HPV-related diseases has to be achieved.12
Most HPV infections are asymptomatic and resolve without
treatment. However, some infections result in epithelial changes or
cancer. Genital infection with low-risk HPV types is associated with
genital warts however, the risk for anal, vulvar, and vaginal cancers is
considerably less.3,13 Women with HPV infection who spontaneously
clear their infection and continue to be HPV DNA negative appear to
be at very low risk for developing cervical cancer. Genital infection in
men with low-risk HPV types is associated with genital warts.14
Prevention of genital HPV infection is important in reducing
prevalence of genital warts, abnormal Pap tests, and cancer. HPV
vaccines is the way of prevention and the new quadrivalent vaccine,
Gardasil®, protects against four HPV types responsible for 70%
of cervical cancers and 90% of genital warts.15,16 The vaccine is
administered through a series of three intramuscular injections over
six-month period (0, 2 and 6 months).17, 18
The quadrivalent HPV vaccine was rst licensed on June 8,
2006, by the Food and Drug Administration (FDA), becoming the
rst licensed vaccine to prevent cervical cancer and related HPV
infections in females between the ages of 9 to 26 years.19,20 In studies
of over 11,000 females (9 to 26 years), the vaccine was found to be
safe and cause no serious side effects except mild injection site pain. 21
Outcome measures:
a) To assess the level of knowledge related to human papilloma virus
(HPV) infection and vaccination among active graduate students
in a private university, Malaysia.
b) To nd the association between knowledge and socio-demographic
variables regarding human papilloma virus (HPV) infection and
vaccination among the study participants.
c) To estimate the effect of educational intervention (pamphlet) tool
in knowledge score modication regarding human papilloma virus
(HPV) infection and vaccination.
Methods and materials
A prospective longitudinal study was designed for repeated
measures, with baseline and post-intervention data (one month apart)
among active graduate students in a private university, Malaysia. The
study was conducted between October and December, 2014. The
questionnaire consisted of two sections, namely, socio-demographic
details and survey items to measure knowledge domain. The
participants included in the study were both male and female students,
aged 18 to 26 years, undergoing graduate education from year 1 to
year 4, and willing to participate in two study phases (one month
apart). Participants with chronic illness, incomplete questionnaires or
no show for either pre- or/and post-test were excluded. The estimated
sample size was 323, calculated based on the total students enrolled
in the graduate programmes of a private university at 95% CI, 5%
margin of error and 50% response distribution. The recommended
sample (20%) was added and rounded off to 390 in order to overcome
any errors and increase the reliability of results.
Development of the questionnaire
The questions for the survey were mostly adapted from other
published articles, designed to test the knowledge domains and
contained the following information: socio-demographic details
like age, gender, etc.; questions to assess knowledge regarding HPV
infection, cervical cancer, its screening and vaccination.22–26 The initial
study questionnaire contained 20 knowledge testing items.
Validation of the questionnaire
The adapted 20 item questionnaire was content validated for its
appropriateness to meet the study objectives by a group of experts
from clinical pharmacy and pharmacy practice, faculty of pharmacy.
The validated questionnaire was later scrutinized by an expert in
Community Medicine from faculty of medicine, AIMST University,
Malaysia. Three questions were removed at this stage as recommended
to be inappropriate.
After a satisfactory content validation, face validation was done
among 30 potential respondents, representing all courses. The
participants were encouraged to inquire any doubt or confusion
regarding the survey items and explained for better understanding and
noted for subsequent corrections. The 17 item questionnaire was thus
arrived.
The reliability test for Cronbach’s alpha coefcient was conducted
to test internal consistency (N=30). The alpha value was found to be.
769 for the initial 17 items. Two knowledge items were removed due
to negative correlations. Hence the nal, 15 item questionnaire with
α value of .862, p<.001, showed good reliability and stability. The
participants in this pilot study were excluded for nal study.
Development of the interventional tool (pamphlet)
The education pamphlet was prepared with information extracted
from Centres for Disease Control and Prevention (CDC)-fact sheet,
2008; Vaccine & Immunization, 2011; WHO/ICO HPV information
centre, 2012; American Cancer Society, 2012&2013.18, 27–31 The
educational pamphlet was prepared with utmost care, so that all
important information’s regarding HPV infection and vaccination
were addressed appropriately and the participants will be able to gain
the necessary knowledge and awareness. The prepared pamphlet was
content and construct validated and pilot tested (N=30) to conrm its
appropriateness and effectiveness.
Modality of obtaining response
The participants were recruited based on convenience sampling,
chosen to counter challenges of tracking the same participants for
two successive data collections. A well-structured and pre-validated
questionnaire was self-administered in class room settings and
brief information was provided regarding the purpose, objectives
and instruction for lling the survey questionnaire. The study was
completely voluntary and participants were allowed to withdraw at
any stage. The informed consent forms were signed before distribution
of survey forms. The completed questionnaires (average time
taken=12-15 minutes) were retrieved and compiled for data analysis.
Scoring grades and scoring pattern
The scoring grades were adopted from the Modied Bloom’s cut
off points,32,33 score of 75-100% correct response was good, 50-74%
was satisfactory, and score<50% was poor knowledge. One mark was
given to each correct response and zero marks for incorrect response.
Sum of all 15 items gave the total knowledge score which was
categorised into good, moderate and poor.

Effect of intervention in increasing knowledge and awareness of Human Papilloma Virus (HPV) infection
and HPV vaccination among graduate students in a private university, Kedah state, Malaysia 189
Copyright:
©2018 Ali et al.
Citation: Ali AN, Ping NY, Prajapati SK. Effect of intervention in increasing knowledge and awareness of Human Papilloma Virus (HPV) infection and HPV
vaccination among graduate students in a private university, Kedah state, Malaysia. MOJ Bioequiv Availab. 2018;5(4):187‒193. DOI: 10.15406/mojbb.2018.05.00101
Ethical considerations
Ethical clearance from the institutional review board (AIMST
University) was obtained and informed consent forms were signed
from participants after providing sufcient information regarding the
purpose of the survey and assured the data will be used for research
purpose only, maintaining high condentiality at all levels.
Statistical analyses of data
The analysis was performed using IBM SPSS Statistics for
Windows (Version 23). Descriptive statistics for frequency and
percentage was computed for categorical variables. Numerical data
was presented as median and interquartile range. The Chi-square
test for independence was used for association between variables.
McNemar’s test and Wilcoxon Sign Ranked Test were used for
inferential statistics to identify differences in knowledge scores
between pre-and post-test. The signicance level was set at .05 for
all statistical tests and p<.05 was considered statistically signicant.
Results
Among the 800 questionnaires distributed, 470(58.8%) valid
questionnaires were retrieved with 41.2% drop-outs.
Socio-demographic characteristics
Among the 470 participants, most of the participants were aged
18-20 years 195 (41.5%), with a median age of 22(5); Females-358
(76.2%); Chinese-357 (76%); pharmacy graduate students-153
(32.6%); year four study-141 (30%) and urban location-320 (69.1%).
The socio-demographic information is presented in Table 1.
Distribution of knowledge score among demographic
variables (Pre-and Post-test)
The knowledge score of pre- and post-test were cross-tabulated
with the socio-demographic variables and the results are summarized
in Table 2. Regarding knowledge score at pre-test, it was observed that
age, course of study, year of study and location showed statistically
signicant differences (p < .01), whereas, at post-test, only course of
study showed any signicance (p<.01) between the two phases (Table
2).
Effect of educational pamphlet on knowledge score
differences
Four hundred and seventy participants were recruited to take part
in an intervention study using structured and validated educational
pamphlets. A pre- and post test was conducted and an exact
McNemar’s test determined that there was a strong, statistically
signicant difference in knowledge score between pre- and post-
intervention test, p<.01.
A pre-test and post-intervention test with correct responses is
summarized in Table 3. The percentage of correct answers increased
signicantly from 45% to 83% [Mdn.=7(6), 1 to 15 vs. 13(2), 7 to
15] between pre- and post-test. Further, the Wilcox on sign ranked
test (N=470) revealed 11 negative ranks, 374 positive ranks and 85
ties at post-test (Z=17.2, N=470, p<.001) with a strong statistical
signicance.
The results at post-test reveals, there was a good knowledge score
and observed the tool to be useful and successful instrument for
expanding users’ knowledge. About 10 out of 15 questions produced
more than 100% increase in knowledge score and only three questions
produced less than 25% increase. There was a signicant increase in
knowledge score for all the 15 items.
Interestingly, knowledge scores at post-intervention did not
vary much by socio-demographic variables. Before accepting the
educational intervention, most of the respondents were not aware of
the nature of vaccine and the frequency of Pap screening done after
30 years of age.
Table 1 Socio-demographic data
Variables Frequency
(N=470)
Percentage
(100.0)
Age in Years
18 - 20 195 41.5
21 - 23 159 33.8
24 - 26 116 24.7
Gender
Male 112 23.8
Female 358 76.2
Race
Malay 7 1.5
Chinese 357 76
Indian 106 22.6
Course of Study
Medicine 125 26.6
Dental 115 24.5
Pharmacy 153 32.6
Others 77 16.4
Year of Study
Year 1 109 23.2
Year 2 115 24.5
Year 3 105 22.3
Year 4 141 30
Location by origin
Rural 320 69.1
Urban 150 31.9

Effect of intervention in increasing knowledge and awareness of Human Papilloma Virus (HPV) infection
and HPV vaccination among graduate students in a private university, Kedah state, Malaysia 190
Copyright:
©2018 Ali et al.
Citation: Ali AN, Ping NY, Prajapati SK. Effect of intervention in increasing knowledge and awareness of Human Papilloma Virus (HPV) infection and HPV
vaccination among graduate students in a private university, Kedah state, Malaysia. MOJ Bioequiv Availab. 2018;5(4):187‒193. DOI: 10.15406/mojbb.2018.05.00101
Table 2 Distribution of knowledge score among demographic variables
Pre -Test Post -Test
Variables N(%) P M G ¥p value P M G ¥p value WSRTǂ
Age in Years
18 - 20 195 (41.5) 157 (80.5) 24 (12.3) 14 ( 7.2) <.001* 0 (0.0) 23 (11.8) 172 (88.2) 0.69
21 - 23 159 (33.8) 63 (39.6) 55 (34.6) 41 (25.8) 1 (0.6) 19 (11.9) 139 (87.4)
24 - 26 116 (24.7) 39 (33.6) 55 (47.4) 22 (19.0) 0 (0.0) 16 (13.8) 100 (86.2)
Gender
Male 112 (23.8) 67 (50.8) 34 (30.4) 11 (9.8) 0.099 1 (0.9) 13 (11.6) 98 (87.5) 0.196
Female 358 (76.2) 192 (53.6) 100 (27.9) 66 (18.4) 0 (0.0) 45 (12.6) 313 (67.4)
Race
Malay 7 (1.5) 3 (42.9) 2 (28.6) 2 (28.6) 0.897 0 (0.0) 1 (14.3) 6 (85.7) 0.944
Chinese 357 (76.0) 198 (55.5) 100 (28.0) 59 (15.5) 1 (0.3) 42 (11.8) 314 (87.9)
Indian 106 (22.6) 58 (54.7) 32 (30.2) 16 (15.1) 0 (0.0) 15 (14.2) 91 (85.8)
Course of studying
Pharmacy 125 (26.6) 57 (45.6) 39 (31.2) 29 (23.2) < .001* 1 (0.8) 12 (9.6) 112 (89.6) 0.009**
Dental 115 (24.5) 51 (44.3) 44 (38.3) 20 (17.4) 0 (0.0) 19 (16.5) 96 (83.5)
Medicine 153 (32.6) 88 46 19 0 (0.0) 26 (17.0) 127 (83.0)
Others 77 (16.4) 63 (81.8) 5 (6.5) 9 (11.7) 0 (0.0) 1 (1.3) 76 (98.7) < .001*
Year of study
Year 1 109 (22.2) 41 (37.6) 39 (35.8) 29 (26.6) <.001* 1 (0.9) 12 (11.0) 96 (88.1) 0.268
Year 2 115 (24.5) 51 (44.3) 44 (38.3) 20 (17.4) 0 (0.0) 19 (16.5) 96 (83.5)
Year 3 105 (22.3) 57 (54.3) 32 (30.5) 16 (15.2) 0 (0.0) 15 (14.3) 90 (85.7)
Year 4 141 (30.0) 110 (78.0) 19 (13.5) 12 (8.5) 0 (0.0) 12 (8.5) 129 (91.5)
Native Location
Urban 320 (68.1) 190 (59.4) 87 (27.2) 43 (13.4) .01* 1 (0.3) 34 (10.6) 285 (89.1) 0.206
Rural 150 (31.9) 69 (46.0) 47 (31.3) 34 (22.7) 0 (0.0) 24 (16.0) 126 (84.0)
¥Chi square test; WSRT , ǂWilcoxon Sign Ranked Test; *(p < .01); ** (p < .05); p < .05 is statistically signicant; P- Poor, M- Moderate, G- Good.
Table 3 Proportion of correct responses, pre- and post-intervention test
Qn.No. Knowledge domain Responses
Questions Pre-test Post-test X2P value
1 HPV infection affects skin and the moist membranes that line the human body. 171(36.4) 421(89.6) 226.28 <.001*
2 HPV can infect (both males and females). 186(39.6) 417(88.7) 192.36 <.001*
3 HPV infects mostly females. 312(66.4) 364(77.4) 15.86 <.001*
4 Women infected with HPV are more likely to get cancer of the cervix. 229 48.7) 419(89.1) 152.65 <.001*
5Those infected with HPV are more likely to get pelvic warts, genital warts, penile
cancer, cervical cancer and some other less common cancers. 196(41.7) 418(88.9) 175.69 <.001*
6 Most people who are infected with HPV do not know that they are infected. 176(37.4) 420(89.4) 212.41 <.001*
7 Signs and symptoms of HPV infection will take few months to years for developing. 193(41.1) 422(89.8) 190.42 <.001*
8 Mostly, HPV infection is transmitted through sexual intercourse. 225(47.9) 420(89.4) 161.53 <.001*
9A vaccine is a biological preparation that improves immunity against a particular
disease. 157(33.4) 421(89.6) 227.53 <.001*

Effect of intervention in increasing knowledge and awareness of Human Papilloma Virus (HPV) infection
and HPV vaccination among graduate students in a private university, Kedah state, Malaysia 191
Copyright:
©2018 Ali et al.
Citation: Ali AN, Ping NY, Prajapati SK. Effect of intervention in increasing knowledge and awareness of Human Papilloma Virus (HPV) infection and HPV
vaccination among graduate students in a private university, Kedah state, Malaysia. MOJ Bioequiv Availab. 2018;5(4):187‒193. DOI: 10.15406/mojbb.2018.05.00101
10 The HPV vaccination prevents HPV infection-associated development of cervical
cancer, penile cancer, genital warts, and some less common cancers. 197(41.9) 420(89.4) 191.77 <.001*
11 The HPV vaccination can be given from the age of 9 to 26 years. 168(35.7) 420(89.4) 215.76 <.001*
12 The course of the HPV vaccination comprises of 3 doses. 409(87.0) 420(89.4) 0.99 0.32
13 The best age for HPV vaccination in girls is between is 9 to 14 years. 183(38.9) 430(91.5) 213.84 <.001*
14 Pap smear test can be used to screen cervical cancer. 275(58.5) 353(75,1) 30.25 <.001*
15 Under 30 years of age, Pap smear test is done once in three years. 82 (17.4) 445(94.7) 33.01 <.001*
Total Median Score 7 (6) 13 (2) - -
Percentage of correct responses 44.8 83.1 - <.001**
*McNemar’s Test (p < .01); **Wilcoxon Signed Rank Test (p < .01); p < .05 is signicant.
Discussion
After carrying out the study, the response rate was found to be
82.8%, 662/800 at baseline (pre-test) and 58.8%, 470/800 response
for both phases (pre- and post-test). Similar responses were reported
in other studies.34,37 The comparatively low response may be due to
reluctance of target samples to answer same questionnaire multiple
times, absenteeism or incomplete forms. A similar trend was
reported in our earlier studies.27,28 Based on their socio-demographics
characteristics, the maximum participation were among those: aged
18-20 years, with median age of 22(5); Females; Chinese; Pharmacy
students; year four study and urban located which was nearly
consistent with other studies.35– 38
Regarding distribution of knowledge score among demographic
variables at baseline (pre-test), age, course of study, year of study and
location showed statistically signicant differences whereas, at post-
test, only course of study showed signicant differences (p<.01).39
The results endorse that female respondents had better knowledge at
baseline.40,41
The Chinese women have the highest rate of cervical cancer
incidence in Malaysia.42 An increasingly positive attitude towards sex
was reported to be seen in both young Chinese men and women, which
demonstrates the women’s right to have sex before marriage. Hook-ups
and casual sexual encounters are increasingly common and accepted
among Chinese men and women. It is further reported, more and more
Chinese women are delaying marriage that motivates women to seek
sex before marriage. Although not all Chinese women feel this way,
for many, pre-marital sex is an opportunity to assert their rights to
sexual freedom. The higher percentage of Chinese participants in this
study attracts additional scope to focus for educational intervention in
this vulnerable, ethnic population.43 A cultural health survey reported,
the sexual habits and behaviours among Muslims report they are less
likely to having had premarital sex than married Jews and Christians.
Muslims are also less likely than afliates of other religions to involve
in premarital sex, gaying, lesbian, oral sex etc. which are prohibited
including multiple sexual partners for women. This explains a much
less probability for a Muslim with HPV infection.44
Among the 470 participants, including medicine, dental, pharmacy
and other graduate students (Engineering, Business etc.) in the
university, all of the respondents at baseline had poor knowledge
score, with higher scores noted among 20-23 years old and rst or
second year of study participants. On an average, the knowledge
scores signicantly improved from 7 to 15 out of maximum 15 score
after intervention (p<.05). These ndings were consistent with a study
in the US.45
The effect of educational pamphlet was tested for knowledge
score differences between pre- and post-intervention studies using
McNemar’s test which determined, there was a strong statistically
signicant positive differences in the participants knowledge scores
after intervention for all the 15 items (p<.01), except one which was
consistent with a study by Berenson et al.45
According to the studies reported, it is shown that generally females
have a relatively higher knowledge compared to the males. In pre-test,
the overall median knowledge score among 358/470 females, was
found to be 7(6) and 13(2) at post-test after pamphlets intervention.
Among the male participants 112/470, the median knowledge score
was 6(5) and 14(2). Though, there were no big differences in scores
between genders, it shows that the participants’ paid good attention to
the HPV related issues and cervical cancer. Female participants also
showed signicant increase in median scores after intervention which
shows, they pay strong attention and interest towards the issue as they
are primarily at risk for HPV related cervical cancer.
As far as race or ethnicity is concerned, the 337/470 Chinese were
the majority of the respondents making up three quarters of the study
population. There was a signicant increase in median knowledge
score, 7(6) at pre-test and 14(2) ranging 7 to 15 at post-test. Most
of the participants were from medical school (125/470), compared
to others; however, pharmacy was not too far behind. There was
a good improvement in median knowledge scores at pre- 9(6) and
14(2) post-test with statistical signicance in knowledge score after
intervention.39
Among the year of study category, year one (109/470) and two
(115/470) had a better median knowledge 9(6)&14(2) respectively for
pre-test, and 8(5)&13(2) for post-test. This may be probably due to
the fact, it is during these early years of study, the healthcare students
undergo pathology, patho-physiology and microbiology related
courses in their curriculum which provides relevant knowledge.
As far as the native location was concerned, more than two third
of the participants were from urban area (320/470). The median
knowledge score did not differ much between urban, 6(6)&13(2) and
rural residents, 8(6)&14(2) among the study population at pre- and
post-test.45,46
Overall, the study showed that active graduate students undergoing
healthcare related courses or otherwise, had poor or average knowledge
score (44.8%) for all the 15 item HPV questionnaire at baseline study,
with the exception of a few questions. Despite being multidisciplinary
graduate students, only 57% had already known about HPV, nearly
49% knew HPV causes cervical cancer, 66% knew it infects mostly
Table continued...

Effect of intervention in increasing knowledge and awareness of Human Papilloma Virus (HPV) infection
and HPV vaccination among graduate students in a private university, Kedah state, Malaysia 192
Copyright:
©2018 Ali et al.
Citation: Ali AN, Ping NY, Prajapati SK. Effect of intervention in increasing knowledge and awareness of Human Papilloma Virus (HPV) infection and HPV
vaccination among graduate students in a private university, Kedah state, Malaysia. MOJ Bioequiv Availab. 2018;5(4):187‒193. DOI: 10.15406/mojbb.2018.05.00101
females and 40%, aware it infects both genders equally. Similar types
of studies conducted in Pakistan and Nigeria reported nearly similar
outcomes.47, 48 In contrast, a study in England, reported that nearly
75% of female participants had heard of HPV, and despite being
aware, only 27% reported HPV causes cervical cancer.16 Similarly,
a Malaysian study among healthcare students reported around 80%
knew HPV causes cervical disease, and nearly 54.6% reported HPV
infects both men and women equally.49
The previous studies carried out in Malaysia showed that awareness
to HPV infection and vaccination in Malaysia was low [50]. However,
it is shown that knowledge is an important factor in inuencing the
perception and attitude of an individual in deciding their practice.
Knowledge inuences the decision making in undergoing Pap smear
and vaccination initiatives. Physicians also play important role in
providing information and recommendations on vaccination.32,33
Conclusion
The ndings shows that even healthcare graduate students are
having poor knowledge regarding the various issues at baseline,
which gives rise to the doubt about the status of general public with
less education and literacy. Therefore, it is strongly suggested that
more exposures should be given to the general public to enrich their
knowledge towards acceptance of HPV vaccination and periodic
screening among the female population so as to decrease the incidence
and mortality due to HPV related infection and cancer. In order to
achieve the goal of reducing the infection rate of HPV in Malaysian,
it is imperative that the health and education systems work together to
deliver the messages to the students and general public at large. Focus
should be given to the susceptible groups, mainly the adolescent and
the young adults still unvaccinated.
Limitations
In spite of taking adequate care to follow the scientically valid
methods for samples, selection bias cannot be ruled out entirely as
only a small proportion of the total target population was studied and
all conclusions are limited to the one university study population only.
The study participants may not have been truthful all the time in their
responses. This study was not able to assess the potentially eligible
population outside the university campus.
Acknowledgements
We acknowledge the management of AIMST University, Malaysia
and the faculty of pharmacy for granting permission to conduct this
study across the faculties. We are also thankful to the participants,
without whose time and cooperation, this study would have been
impossible.
Conict of interest
The author declares that there is no conict of interests involved
in this study.
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