KNOWLEDGE AND AWARENESS OF NURSING STUDENTS REGARDING HUMAN PAPILLOMAVIRUSES INFECTION AND VACCINATION

Background/Aim: Human papillomaviruses (HPV) is the most common sexually transmitted infection. Most HPV infections are transient and asymptomatic. Routine vaccination against HPV is the best prophylaxis against HPV infection. The aim of present study was to determine knowledge and risk factors about HPV infection, and the attitudes towards vaccination against HPV infection among nursing students. Methods: This cross-sectional study was conducted in a random sample of 175 nursing students. For statistical data analysis was done with t-test for and Mann-Whitney U test. Results: Most respondents (93.1%) knew that HPV infection may cause cervical cancer, and that it is a sexually transmitted infection (80.0%). Only 31.4% were aware that HPV may cause head and neck cancer and only 22.9% were aware that smoking is a risk factor for HPV infection. Male respondents ( p =<0.05) and third-year respondents ( p =<0.05) were significantly aware that men can be infected with HPV. Third-year respondents were significantly aware that early sexual intercourse increases the risk of HPV infection ( p =<0.05), that HPV infection can be asymptomatic ( p =<0.05). Respondents below 26 years ( p =<0.05) and first-year respondents ( p =<0.05) were significantly aware that men can also be vaccinated against HPV infection. Conclusion: The present study found that the respondents emphasised the importance of health education by nurses and vaccination against HPV infection. Due to the low vaccination rate of the population, preventive measures are needed to increase public awareness about vaccination against HPV, for which nurses are also responsible.


Introduction
Papillomaviruses from the group of genotypes relevant for human medicine are called human papillomaviruses (HPV). HPV is the most common sexually transmitted infection 1 . The virus is transmitted via close contact with the skin or mucosa of an infected person, such as contact of the genital area, vaginal, anal or oral sex between heterosexual or homosexual partners. Routine use of condoms does not fully protect against HPV infection.
HPV infection is very common after sexual activity starts, between the ages of 20 and 24.
Infection may occur during the first months after the first sexual activity. Even though the majority of sexually active adults have been exposed to HPV, new HPV infections may develop with a new sexual partner 2 . Thus, a second, milder increase of HPV infections is noticed in women around the age of 55 3 . Risk factors for HPV infection include early start of sexual activity (before the age of 15), numerous sexual partners (7 or more), unprotected sex, HPV oncogenicity, smoking, long-term use of oral contraceptives (progesterone), other sexually transmitted infections and diseases (herpes simplex, chlamydia, gonorrhoea, HIV), low socioeconomic status 4,5 .
Most HPV infections are transient and asymptomatic, and do not cause any clinical problems 6 . Due to cell-mediated immunity, infection is usually transient and mostly (80-90%) resolves by itself within one to two years. Since a person is often unaware of their infection, HPV can be rapidly transmitted between sexual partners 7,8 . Rarely, oncogenic HPV types remain present (10%), causing a persistent infection. The persistence of the infection is associated with oncogenesis 5 . After several years (7-10 years), persistent HPV infection may progress to precancerous lesions or cervical cancer and other anogenital and/or oropharyngeal cancers 4,9 . Routine vaccination against HPV is the best prophylaxis against HPV infection and HPV-associated diseases, including some cancers; therefore, it was introduced into national immunisation programmes in all EU countries, except Poland, between 2006 in 2018 10 . The primary target group are youths between 9 and 14 years old previously not exposed to HPV infection or who have not been sexually active. This is due to the fact that the vaccine is more immunogenic in people younger than 26 years. Also, vaccination against HPV is most effective before potential exposure to HPV infection, i.e. before the first sexual contact. Protection following vaccination against HPV infection lasts for at least 10 years, and is expected to be long-lasting 11,12 . There are currently three licensed prophylactic vaccines against HPV. The vaccination scheme for all three vaccines depends on the age of the recipient. For those below 15 years, two doses are recommended (at 0, 6 months), and three doses (at 0, 2, 6 months) for those above 15 years 13,14 . Vaccination is also effective after the start of sexual activity, but the person is only protected against those virus genotypes with which they have not been infected at the time of vaccination 15 . In 2015, the Advisory Committee on Immunization Practices introduced a catch-up vaccination for young women (between 13 and 26 years) and young men (between 13 and 21 years, and 26 years for high-risk men), who have not previously been vaccinated 6 . Catch-up immunisation programmes have been established in 10 countries 16 . Anti-HPV antibodies persist several years after vaccination at levels significantly higher than those following the natural course of infection 14 . Vaccination efficacy is high, preventing up to 90% of cervical cancer cases. In addition to girls, some countries around the world also vaccinate boys.
This option has been available in Denmark since 2006. Until 2014, only 4239 Danish males between 9 and 26 years were vaccinated 17 . Since 2013, Australia has provided free vaccination for boys up to the age of 15 18 . During HPV infection, seroconversion in men is lower, so vaccination against HPV is the most reliable method for immunoprotection against HPV infection and risk of cancer. The proportion of HPV infections in young men is equal to that in young women; however, the proportion of infections in women considerably declines with age, which is not the case seen in older men 19 . Due to the low vaccination rate of the population, preventive measures to increase public awareness about vaccination against HPV are needed. Healthcare professionals need evidence-based expertise, since their task is to make efforts to reduce the number of HPV infections 22 through health education and preventive programmes 23 . In doing this, they should be focused on the younger population, which is particularly at risk, also due to poor awareness 24 . The aim of present study was to determine knowledge and risk factors about HPV infection, and the attitudes towards vaccination against HPV infection among nursing students.

Methods
All of 214 nursing students who attended a 3-year undergraduate nursing program at the Faculty of Health Sciences in Slovenia were invited to participate in the research. This cross-sectional study included in total 175 nursing students who completed the questionnaire. The response rate was 82%. First and second year nursing students did not have theoretical and clinical education about women's health nursing. Third year nursing students received women's health nursing theoretical content (45 hours). The study was conducted from December 2017 to January 2018.
This study was reviewed and approved by the institutional review board at an institution. A written explanation of the study's procedure was given to the participants. It also was explained about the autonomy of participating and the right to stop and withdraw from the study at any time. The questionnaires were distributed during lecture hours. The respondents were explained the content of the study. The questionnaires were returned directly to the researchers in a closed envelope. Instructions, on how to complete the survey, were included, as well as a cover letter indicating the study purpose. The nursing students participated on a voluntary basis and were reassured of data confidentiality, as well as anonymity.
The questionnaire was constructed on the basis of the literature review [25][26][27][28][29] . A questionnaire was specially designed for purposes of this study. A pilot study was Descriptive statistics were derived and expressed as frequency and percent.
Categorical data were compared using the t-test for independent samples for between group differences by gander and Mann-Whitney U test for between group differences by age, year of study and place of residence. A p-value <0.05 was considered statistically significant.
Data were analysed by SPSS IBM v. 23 for Windows (IBM Corporation).

Results
The sample included 175 nursing students. The median age among all respondents was 20 (range, 19-43), and the mean age was 21,5±4,7. The majority of the sample was female (78.9 %), lived in the rural area (60 %) and first-year of study 40.6 % ( Table 1).  between respondents who had until the age of 26 and >26 years' (Table 3).  Third-year respondents believe that Vaccination against HPV infection is effective and would thus recommend it, there was a statistically significant differences (Z=-2.658; p=<0.05), between respondents who had third-year and those who had of other years of the study. Among New Mexico nursing students, it was found that more than half were unaware that men can get infected with HPV and vaccinated against HPV infection 26 . In the USA, it was found that only 50% of men had heard of HPV, of which 53% were unaware that they can get vaccinated against HPV 36 . Insufficient knowledge was also observed in India among medical students, only 18.8% of whom were knew that men and women could be vaccinated up to the age of 26 24 . As many as 65% of Swedish girls with a mean age of 18 years were vaccinated against HPV after their first sexual intercourse 37 40 . Healthcare professionals should provide effective healthcare education in order to increase awareness and reduce the burden of precancerous changes, which have become increasingly common in the last decade 41 . In particular, they should encourage the youth to get vaccinated and inform them about the consequences of (too) early, high-risk and unprotected sex 26 . Collective immunity can only be achieved through vaccination of girls and boys against HPV infection. One would expect that nursing students, being future healthcare professionals, trust the efficacy of the vaccine.
This study has the limitation of being a single-centre study with a small sample size.
The survey was conducted on only one geographical area. Thus, the results cannot be generalised to all nursing students. Another important limitation was that we surveyed nursing students of all academic years, with only third-year students completing lectures in oncology and gynecology. The important aspect of this study was to demonstrate the respondents emphasised the importance of health education by nurses.

Conclusion
The present study found there was insufficient knowledge among nursing students regarding risk factors and vaccination against HPV infection. The respondents emphasised the important role of nurses in raising awareness about HPV. Being future healthcare professionals, they need evidence-based expertise about HPV infection and its consequences, and about vaccination against HPV infection, allowing them to act preventively. Improvement of knowledge regarding HPV and raising awareness among young girls and boys provides great health benefits, by reducing the morbidity and mortality associated with HPV infection and transmission. Similarly, it is important for young people to trust healthcare professionals whose expertise contributes to increased awareness encouraging them to get vaccinated against HPV.