Final presentation for Doctoral Capstone project

1. The Effect of an Educational Program for Nursing Students on HPV Disease and Vaccine Colleen R. Barrett, MSN, CRNP, DNP (c) Principal Investigator Mary Cothran, PhD, CRNP, FNP-BC Capstone Advisor

2. Purpose To determine the effect of an educational program about human papillomavirus (HPV) on the knowledge base of baccalaureate nursing students

3. Implications for Study Limited research has shown a knowledge deficit about HPV among nursing students Educational programs on HPV for this group may translate to improved personal and public health

4. Background and Significance HPV Most common STI in the US (1,2) Infects 6.2 million US residents annually (1)

5. Background and Significance HPV Over 100 strains; at least 40 known to be oncogenic (3). Types 6 and 11-low risk. Cause majority of genital warts (condyloma) (4). Types 16 and 18 most oncogenic. Together cause over 80% of cervical cancers (4).

6. Cervical Cancer In the US in 2005 (7) 11,999 newly diagnosed 3,924 died of the disease

7. Cervical Cancer Worldwide (9) HPV causes over 500,000 cases of genital cancers annually 370,000 of those are known cervical cancers 270,000 of those will lead to death

8. HPV prevention Primary prevention of the human papillomavirus is now possible.

9. HPV PREVENTION Vaccination June 2006: prophylactic, quadrivalent HPV 6/11/16/18 VLP vaccine (Gardasil) was licensed for use Indicated for males and females ages 9-26 Has been shown to prevent up to 70% of cervical cancers caused by HPV 16/18 (14).

10. Knowledge Deficit Numerous surveys on college campuses in US and Canada: Low level of HPV knowledge among college students and nursing students

11. Knowledge Deficit Ingledue, et al. College students Denny-Smith, et al. nursing students Both studies revealed poor knowledge, low perception and high risk sexual behaviors

12. Knowledge Deficit Data support the need to educate adolescents and women about HPV Studies reveal women desire more information about HPV (24)

13. HPV Education Few studies on effect of HPV-focused educational programs Lambert (25) evaluated the effectiveness of a brief HPV focused educational program Physician Assistant and Psychology students Data revealed statistically significant improvement in HPV knowledge scores after the program

14. STD and Pregnancy Prevention Programs Have been shown in literature to be successful Anderko and Uscian (22) Studied decreasing risky sexual behavior Kirby Research review revealed success with educational programs on HIV prevention

15. Study Design Pre-test/Post-test

16. Sample Convenience sample of full time senior level undergraduate nursing students (n=18) Demographic data analyzed using frequencies and averages Mean age of students was 22.53 years (SD 1.13) –after removal of 3 outliers (ages 33, 37, 42)

17. Sample Participation was voluntary Completion of study materials considered implied consent No incentives offered for participation Study approved by IRB at RMU and Human Subject’s Review Board at host university

18. Instrument The Awareness of HPV and Cervical Cancer Questionnaire (23) 40 item multiple choice questionnaire Developed to assess knowledge, perceptions, and preventive behaviors regarding HPV and cervical cancer

19. Instrument Permission to use granted by author, Ingledue (23) Stability reliability established by test-retest procedures Test-retest coefficients of 0.90 reported for knowledge; 0.95 for perceptions and 0.90 for behaviors

20. Instrument No data reported for internal consistency Content validity established via consensual validity using a panel of health experts Instrument was approved by a Human Subject’s committee

21. Instrument For present study, only the knowledge items of the instrument were used Multiple choice questions One correct answer Correct answers assigned one point Score range of 0 to 15

22. Data Collection Demographic questionnaire with cover letter describing study Questionnaires numbered by author Pre-test/post test-numbered by participants All placed in privacy envelopes upon completion.

23. Educational Intervention Objectives Increase general knowledge of HPV disease and its sequelae Identify- Risk factors for HPV and cervical cancer Symptoms of HPV infection Means to prevent HPV and cervical cancer Means of detecting HPV and cervical cancer

24. Educational Intervention Content: HPV types HPV incidence, prevalence and pathogenesis HPV risk factors and sequelae Various stages of cervical dysplasia and cervical cancer Cervical cancer statistics Knowledge deficit Quadrivalent HPV vaccine

25. Educational Intervention Concluded with open question and answer period

26. Data Analysis Data entered into Access Excel Paired t-test Analysis performed using SPSS 17.0

27. Results Mean of pre-test: 10.83 (SD 1.043) Mean of post-test: 13.78 (SD 1.166) t=7.517(7), p=.000

28. Discussion Mean pre-test score: 72% Mean post-test score: 91%

29. Discussion Undergraduate nursing students Will be able to disseminate accurate information about HPV disease and vaccine to patients May be of the age group recommended to receive the vaccine themselves Improved knowledge in this group may contribute to public health both directly and indirectly

30. Discussion Study limitations Small sample size Homogeneity of sample Vaccine knowledge not assessed 38.9% of students reported some previous education on HPV disease Entire tool not utilized

31. Future Research Should include larger sample size Nursing students in various pre-licensure programs More heterogeneous sample Assess knowledge retention over time Vaccine knowledge (instrument development) Vaccination status pre- and post-program Include practicing nurses and their practice habits as they pertain to patient education

32. Implications for Study HPV incidence and subsequent cervical disease burden may be reduced through education of nurses Nurses can have positive effect public health as they disseminate accurate information

33. References 1. Fontenot HB, Collins Fantasia H, Allen JD. HPV in adolescents: Making the wake up call. Adv Nurse Pract. 2007;15(10): 73-76. 2. Denny-Smith T, Bairan A, Page M. C. A survey of female nursing students’ knowledge, health beliefs, perceptions of risk, and risk behaviors regarding human papillomavirus and cervical cancer. J AmAcad Nurse Pract. 2006;18:62-69. 3. O’Brien J. 11th annual conference on vaccine research. Expert RevVaccines. 2008;7(6):721-723. 4. Bosch, FX, & de Sanjose, S. (2003). Chapter 1: Human papillomavirus and cervical cancer burden and assessment of causality. J Natl CancerInst Monogr. 2003;31;3-13

34. References 5. Walboomers JMM, Jacobs M, Manos N, Bosch F, Kummer A, Shah K. Human papillomavirus is a necessary cause of invasive cervical cancer worldwide. J Pathol. 1999;189:12-19. 6. Oaknin A, Pilar-Barretina M. Human papillomavirus vaccine and cervical cancer prevention. Clin and Transl Oncology. 2008;10:804-811. 7. Cervical cancer statistics. Centers for Disease Control Website. http://www.cdc.gov/cancer/cervical/statistics/index.htm. Updated July 20, 2009. Accessed September 3, 2009. 8. Buttin B, Herzog T, Mutch D. Abnormal cytology and human papillomavirus. In: Curtis M, Overholt S, Hopkins M. Glass’ Office Gynecology. 6th ed. Philadelphia, PA: Lippincott, Williams and Wilkins; 2006:80-106

35. References 9. Block S, Nolan T, Sattler C, Barr E, Giacoletti KED, Marchant CD, et al. Comparison of the immunogenicity and reactogenicity of a prophylactic quadrivalent human papillomavirus (types 6, 11, 16, 18) l1 virus-like particle vaccine in male and female adolescents and young adult women. Pediatrics. 2006;118(5);2135-2145. 10. Future I Study Investigators. Quadrivalent vaccine against human papillomavirus to prevent anogenital diseases. N England J Med. 2007;356(19):1928-1943. 11. Parkin D, Pisani P, Ferlay J. Estimates of the worldwide incidence of mortality from 25 cancers in 1990. Int J Cancer. 1999;80:827-841.

36. References 15. Cancer Prevention & Early Detection Facts & Figures. American Cancer Society Website http://www.cancer.org/downloads/STT/CPED_2008.pdf. Reported as of November 30, 2007. Accessed September 3, 2009. 16. Nanda K, McCrory DC, Myers ER, et al. Accuracy of the Papanicolaou test in screening for and follow-up of cervical cytologic abnormalities: a systematic review. Ann Intern Med. 2000;132:810-819. 17. Adams M, Jasani B, Fiander, A. Human papillomavirus (HPV) prophylactic vaccination: challenges for public health and implications for screening. Vaccine. 2007;25:3007-3013.

37. References 18. Future II study group. Quadrivalent vaccine against human papillomavirus to prevent high-grade cervical lesions. N Engl J Med. 2007;356(19):1915-1927. 19. Zimet GD, Liddon N, Rosenthal SL, Lazcano-Ponce E, Allen B. Psychosocial aspects of vaccine acceptability. Vaccine. 2006;24S3, S3/201-S3/209. 20. Ramirez J, Ramos D, Clayton L, Kanowitz S, Moscicki. Genital human papillomavirus infections: Knowledge, perception of risk, and actual risk in a nonclinic population of young women. J Womens Health. 1997;6:113-121.

38. References 21. Pitts M, Clarke T. Human papillomavirus infections and risks of cervical cancer: what do women know? Health Educ Res. 2002;17(6):706-714. 22. Baer H, Allen S, Braun L. Knowledge of human papillomavirus infection among young adult men and women: implications for health education research. J Community Health. 2000;25:67-78. 23. Yacobi E, Tennant C, Ferrante J, Naazneen P, Roetzheim R. University students' knowledge and awareness of HPV. Prev Med. 1999; 28:535-541.

39. References 24. Zimet GD. Improving adolescent health: focus on HPV vaccine acceptance. J Adolesc Health. 2005;37:19-23. 25. Anderko L, Uscian M. Academic-community partnerships as a strategy for positive change in the sexual behavior of rural college-age students. Nurs Clin North Am. 2002;37:341-349. 26. Ingledue K, Cottrell R, Bernard A. College women’s knowledge, perceptions, and preventive behaviors regarding human papillomavirus infection and cervical cancer. Am J of Health Stud. 2004;19(1):28-34.

40. References 27. Holcomb B, Bailey J, Crawford K, Ruffin M. Adults' knowledge and behaviors related to human papillomavirus infection. J Am Board Fam Practice. 2004;17(1):26-31. 28. Lambert E. College students’ knowledge of human papillomavirus and effectiveness of a brief educational intervention. J Am Board Fam Pract. 2001;14(3):178-183. 29. Kirby D. Emerging answers: research findings on programs to reduceteen pregnancy (summary). Washington, DC: National Campaign to Prevent Teen Pregnancy. 2001.