eH m ea f o lth Community Medicine & Health Education · deaths in 2025 is 15,251 (Nigeria Human Papilloma Virus summary report). This clearly shows that cervical cancer is a serious

Volume 2 • Issue 11 • 1000191J Community Med Health EducISSN: 2161-0711 JCMHE, an open access journal

Odetola and Ekpo, J Community Med Health Educ 2012, 2:11 DOI: 10.4172/2161-0711.1000191

Research Article Open Access

Nigerian Women’s Perceptions about Human Papilloma Virus ImmunisationsOdetola TD* and Ekpo K

Department of Nursing, University of Ibadan, Oyo state, Nigeria

AbstractAlthough cervical cancer remains a common condition in Nigeria, with a reported prevalence of 23.7% (21.1-26.4)

among 1030 women with normal cytology and an incidence of 19.3% per 100,000 women per year, only the minority of Nigerian women have used human papilloma virus (HPV) immunisation services. This study was thus out to identify the reasons for this low patronage.

This descriptive study took place among women attendees of an immunisation clinic in Nigeria. The clinic is adequately stocked with all the immunisation in Nigeria schedule including HPV vaccination and enjoys high patronage by different economic, cultural and religious groups. The study explored their perception about the Human Papilloma Virus vaccine which was introduced in 2009 to mitigate the rising scourge of cervical cancer globally.

One hundred and seventy nine women aged 16 to 45 years who accessed the clinic for various immunization services and regimens participated in the study after the purpose of the research was explained and their informed consent sought and gained.

The study revealed that though women’s awareness level about cervical cancer had increased, knowledge about the human papilloma virus and the vaccine was still poor. It identified some reasons for the low uptake of HPV vaccination and revealed that women were willing to be vaccinated if they were properly educated about the need for the vaccine which should be well subsidized by the government.

*Corresponding author: Odetola TD, Department of Nursing, University of Ibadan, Oyo state, Nigeria,Tel: ++234(0)8055410093, ++234(0)8060227398; E-mail: [email protected]

Received November 26, 2012; Accepted December 28, 2012; Published December 29, 2012

Citation: Odetola TD, Ekpo K (2012) Nigerian Women’s Perceptions about Human Papilloma Virus Immunisations. J Community Med Health Educ 2:191. doi:10.4172/2161-0711.1000191

Copyright: © 2012 Odetola TD, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Keywords: Human papilloma virus; Immunization; Nigerianwomen; Perception

Introduction and Background InformationCervical cancer is the second most common cancer among women

worldwide (next only to breast cancer), with an estimated 529,409 new cases and 274,883 deaths in 2008. About 86% of these cases occur in developing countries [1]. Worldwide, cervical cancer mortality rates are lower than incidence with a ratio of mortality to incidence of 52%. The crude incidence rate of cervical cancer is 19.3 in Nigeria, 19.9 in Western Africa and 15.8 worldwide. In Nigeria, current estimates indicate that every year 14,550 women are diagnosed with cervical cancer and 9,659 die from the disease. Cervical cancer ranks as the 2nd most frequent cancer among women in Nigeria, and the 2nd most frequent cancer among women between 15 and 44 years of age (Nigeria Human Papilloma Virus summary report). Cervical cancer occurs rarely in women under 30 years of age, and occurs most commonly in women over 40. Since it’s also associated with the early age at which sexual intercourse begins, it remains a problem in African countries.

Prevalence of sexually transmitted infection is highest in the 15 to 24 years age group because they are exposed to multiple risks and opportunities. Human Papilloma Virus (HPV) is a sexually transmitted disease that is most commonly transmitted between people during vaginal or anal intercourse. But it can also be transmitted through genital-to-genital, or hand-to-genital contact. About 80 percent of all people who had sex would have come in contact with HPV which is a sexually transmitted infection (STI) that can either produce vaginal warts or lead to cancer. Genital HPV is the most common sexually transmitted infection and is more common in young people probably because immunity is developed to the virus as people get older [2]. Factors contributing to development of cervical cancer after HPV infection include immune suppression [3], multiparity, early age at first delivery, cigarette smoking, long-term use of hormonal contraceptives, and co-infection with Chlamydia trachomatis or Herpes simplex virus [4].

Together, HPV types 16 and 18 currently cause about 70% of cervical cancer cases. HPV types 6 and 11 cause about 90% of genital

wart cases. However, few years ago, new vaccines were discovered against the HPV infection and cervical cancer which were produced through combination of genetic material from more than one origin. Since the vaccines do not contain any live biological product or DNA, they are non-infectious. The HPVs targeted by the vaccines are ‘high risk’ types 16 and 18 and ‘low risk’ types 6 and 11 [5]. HPV vaccines have also been shown to prevent precursors to some other cancers associated with HPV [6]. HPV vaccines induce high levels of serum antibodies in virtually all vaccinated individuals and are generally well tolerated with minor adverse events at the injection site like pain, erythema and oedema.

Clinical trials were completed on two vaccine formulations and these were commercially released world-wide in government sponsored vaccination program that target women, girls and even boys as young as nine years of age in a bid to prevent cervical cancers [7]. Vaccinating boys becomes crucial because primarily, men carry HPV and infect women during sexual intercourse. The vaccines currently available prevent both vaginal and cervical strains, though they must be given before the infection emerges.

Vaccination with HPV 16/18 L1 vaccine provides no benefit for women with pre-existing infection and may leave them more susceptible to other oncogenic HPV types therefore cervical cancer should be ruled out through Pap smear before HPV vaccine is administered. Though women could be infected by HPV at any age, infections at a very young

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age could be dangerous because they have more time-line to cause damage that eventually leads to cancer. Despite vaccination, women still need to continue cervical cancer screening on account of the risk exposure to other oncogenic HPV types and the unknown duration of the anti-HPV immunity [8].

HPV vaccines are targeted at girls and women of ages 9 to 26 because it is only useful if given before infection occurs. This is because the HPV vaccines are designed to be prophylactic (i.e. to prevent infection and consequent disease), not therapeutic. Therefore, public health workers target girls before they begin having sex especially in deprived areas. The vaccines have been shown to be effective for at least 4 to 6 years, and it is believed they will be effective for longer, however the duration of effectiveness and whether a booster will be needed is unknown. One vaccine protects against all four HPV types because it contains virus like particles with mixtures of four subunit proteins and is called a tetravalent vaccine. The vaccines contain an aluminum adjuvant. Protection requires a first inoculation and booster shots at one and six months after the first. The four subunit proteins are manufactured using genetically modified baker’s yeast. The other vaccine is a bivalent vaccine containing an aluminum adjuvant along with a compound called 3–0–deacyclated-4-monophosphoryl lipid A [9].

The cost of vaccination is an obstacle to global deployment. The production cost of the vaccine’s active ingredient is around $3million per gram which seems a bit pricey for yeast fermentation. Producing edible vaccines in transgenic crop plants is being proposed as a cheaper alternative but that approach is beset with problems of contaminating food crops, drinking water and the general environment [10]. In the meantime, there has been pressure on policy makers worldwide to introduce the HPV vaccine in national or statewide vaccination programs [7].

The vaccine against HPV types 6, 11, 16 and 18, though licensed but currently not available in Nigeria due to importation, distribution, and other regulatory requirements, as well as price negotiations issues, is believed to be about 98% effective against these strains of HPV and given in three doses over a six month period. However, a vaccine which targets both HPV strains 16 and 18 and proven to be 92% effective with more than four years potency is both licensed and available in Nigeria [11]. In April 2009, WHO issued a position paper on HPV vaccination. It recommended that routine HPV vaccination be included in national immunisation programmes, provided that cervical cancer or other HPV-related disease prevention measures are a public health priority for the country [12].

The vaccine is available and accessible at some private and public hospitals in Nigeria at a cost range of nine thousand naira to fifteen thousand naira (N9, 000:00–N15, 000:00) [13]. Despite the prevalence and burden of cervical cancer worldwide with almost 80% occurring in developing countries such as Nigeria, only about 52% of Nigerian women were aware of this deadly disease [14]. Less than 7.1% of Nigerian women have reportedly had cervical cancer screening done and only 8% of women who attended the clinic between 2010 and 2011 had HPV vaccination.

Statement of the Research ProblemThe vaccines were licensed and introduced in Nigeria in 2009 to get

sexually active women and virgins inoculated. However, the available vaccine is discussed to be expensive and beyond the reach of an average Nigerian citizen considering the present socio-economic burden on women in particular. This created concern for the researchers because

though vaccines are available, and the fact that the clinic where the study was conducted enjoys high patronage from women and children, yet just very few have been immunised against HPV since its introduction. This became expedient as a result of the high incidence and prevalence of cervical cancer and associated deaths.

Purpose of the StudyA population of 40.43 million women between the ages of 15 years

and above are at risk of developing cervical cancer and about 9, 659 die from the disease in Nigeria. Projected number of new cervical cancer cases in year 2025 is 22,914 and the projected number of cervical cancer deaths in 2025 is 15,251 (Nigeria Human Papilloma Virus summary report). This clearly shows that cervical cancer is a serious public health concern in Nigeria. Despite the fact that Human Papilloma virus vaccine is available, very few women have been vaccinated. This study was thus out to investigate women’s awareness of the cervical cancer, the vaccines and explore perceived barriers to low uptake of HPV vaccine.

ObjectivesThe researchers sought to assess the level of knowledge about

cervical cancer and human papilloma virus; evaluate attitude towards vaccination; and identify the perceived barriers to vaccination among women at an immunisation clinic in Nigeria.

Definitions of Keywords/Concepts Human papilloma viruses (HPV’s) are DNA viruses that infect

epithelial (skin or mucosal) cells. There are more than 100 known HPV genotypes, which are numbered in order of their discovery.

Immunisation is the process of deliberate introducing potent human papilloma vaccine into the body for the purpose of protecting against cervical cancer.

A Nigerian woman is a female in her reproductive age that had come to access any type of immunisation at the selected clinic.

Perception refers to the level of awareness and attitudes about HPV vaccines and the perceived barriers responsible for non- utilization of the vaccines.

Research MethodologyThis study, a descriptive survey, was carried out in Ibadan at one

of the two locations where the researchers noticed that HPV vaccines were available in Ibadan as at the time of conducting the research.

The study population included all the women aged 16 to 45 years in the selected centre who attended the immunisation clinic and had not been diagnosed of having cervical cancer as at the time of the administration of questionnaire. There were two clinic days per week and the average number of clients per day was 25. The data collection ran through a period of 4 weeks (14th June to 9th July, 2010). During this period, a total of 204 women who were eligible turned up for their wards’ immunisation and they were all encouraged to participate in the study because of the small number. However, 179 women were willing and participated in the study during the period of administration, after the purpose of the study had been explained to them and their informed consent sought and gained. Same was documented through signature and thumbprints from non-literate participants. The participants were informed that they could withdraw from the study whenever they chose without any prejudice or negative effect on the care they sought. Also, twenty-five women declined participating in the study.



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A self-developed questionnaire containing 50 items was developed from the literature reviewed with some open and close-ended questions. The questionnaire consisted of 5 sections: Section A: Demographic data; Section B: Knowledge about cervical cancer; Section C: Knowledge about human papilloma virus vaccine; Section D: Attitude of women towards vaccination; Section E: Perceived barriers to vaccination. Same was translated to major Nigerian languages for ease of understanding. It was also interpreted to non- literate respondents.

The content of the questionnaire was thoroughly read, critiqued and validated by experts in the field of cervical cancer issues. The reliability of the instrument was achieved by pre-testing 20 (10%) women attendees of the second center where the vaccine was also available with reliability co-efficient of 0.8. The instrument was adjusted using the feedback from the pretest [15].

Raw data was screened manually for inconsistencies. A total of 179 questionnaires was analyzed (N=179) using descriptive statistics.

ResultsFrom table 1 out of the 67.6 percent that knew what cervical cancer

was, 65.4 percent could identify its symptoms and 22.3 percent were

aware of how to prevent the disease. Twenty three percent identified HPV immunization as a prevention against cervical cancer and only 46.9 percent knew the treatment modalities.

In table 2 the results showed that 83.8% of the respondents had heard of HPV and 45.8 percent of them from health personnel. About thirty percent of them agreed that sexual intercourse at early age was a risk factor. About 20% of the respondents knew that smoking also predisposes to cervical cancer and 67% associated HPV with cervical cancer and genital warts.

From table 3 above, almost 23% of the women opined that the vaccine was too expensive and 79.3% felt its cost should be highly subsidized by the government. Though 39.5% had heard of the vaccine, but only 20.7% of the women claimed to have received the vaccine. Culture and religion were not considered deterrent to receiving the vaccine and only most respondents were of the opinion that adequate information about the vaccine was not provided by nurses.

Discussion of Research ResultsThe study revealed that most of the women at the clinic had at least

their high school education and were not from the low socio-economic group only. These women were found to be aware of cervical cancer unlike what they reported in her study at Owerri, Nigeria that just 52% of his respondents were aware of cervical cancer. Few women were aware of the availability of the vaccine and most women expressed their willingness to be vaccinated if adequately enlightened and the cost subsidized; this finding was in line with the health belief model which stated that a set of factors called “cues to action” triggers or initiates appropriate health behavior.

Areas of knowledge Frequency Percent Cumulative percent

1. What is cervical cancer?a. Abnormal malignant growth of cervix 121 67.6b. Abnormal malignant growth of vagina 24 13.4 81c. Small growth in the womb 12 6.7 87.7d. I don’t know 18 10.1 97.7e. No response 4 2.2 100.0Total 179 100.02. Signs of cervical cancer Frequency Percent Cumulative

percenta. Pain during intercourse 42 23.5b. Vaginal bleeding 34 19.0 42.5c. All of the above 41 22.9 65.4d. I don’t know 58 32.4 97.8e. No response 4 2.2 100.0Total 179 100.03. How to detect cervical cancer Frequency Percent Cumulative

percenta. Pap test 114 63.7b. Fluoroscopy 19 10.6 74.3c. I don’t know 44 24.6 98.9d. No response 2 1.1 100.0Total 179 100.04. How can cervical cancer be treated Frequency Percent Cumulative

percenta. Surgery 71 39.7b. Cryotherapy 11 6.1 45.8c. All of the above 2 1.1 46.9d. I don’t know 74 41.3 88.3e. No response 21 11.7 100.0Total 179 100.05. How to prevent cervical cancer Frequency Percent Cumulative

percenta. By using condom 30 16.8b. Personal hygiene 47 26.3 43.1c. HPV Immunisation 41 22.9 66.0d. All of the above 40 22.3 88.3e. No response 21 11.7 100.0Total 179 100.0

Table 1: Knowledge about Cervical Cancer.

1. What is human papilloma virus Frequency Percent Cumulative percent

a. An infection 36 20.1b. A virus 114 63.7 83.8c. I don’t know 18 10.0 93.8d. None of the above 3 1.7 95.5 e. No response 8 4.5 100.0Total 179 100.02. Risk factors for human papilloma virus

Frequency Percent Cumulative percent

a. Smoking 38 21.2b. Early age at sexual intercourse 57 31.8 53.0c. All of the above 36 20.1 73.1d. None of the above 31 17.3 90.4 e. No response 17 9.5 100.0Total 179 100.03. What does human papilloma virus cause

Frequency Percent Cumulative percent

a. Measles 10 5.6b. Hepatitis 14 7.8 13.4c. cervical cancer and genital warts 120 67.0 80.4d. I don’t know 25 14.0 94.4e. No response 10 5.6 100.0Total 179 100.04. Source of knowledge Frequency Percent Cumulative

percenta. Friend 18 10.1b. Medical personnel 82 45.8 55.9c. Poster/ television/ radio 45 25.1 81.0d. Others 15 8.4 89.4e. No response 19 10.6 100.0 Total 179 100.0

Table 2: Knowledge of Women on Human Papilloma Virus.



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Majority (63.7%) of these women also knew that Pap test could be carried out to detect the abnormal malignant cervical cells but lacked adequate knowledge about the human papilloma virus. Culture and religion were not seen as barriers to receiving the vaccine.

The study further revealed that the cost of the vaccine and inadequate education from the health personnel reduced awareness about the vaccine. In agreement with the findings of [16] study, the vaccines should be included in the National immunisation program and at a subsidized rate. Although, Alabi et al. [13] indicated that the vaccine was accessible at private hospitals and some public hospitals in the country at an affordable rate, the study showed that awareness was poor because vaccines could only be found at few locations and at relatively high cost.

ConclusionsTo bring this study to a conclusion, it is important to state that

health awareness is the key to healthy living.

Several deadly diseases of which cervical cancer is one need to be tackled with an equally determined and comprehensive approach to the issue surrounding its causes and prevention in developing countries.

Factors identified in the study to be of significance to the poor compliance with immunisation included poor publicity, affordability and availability of HPV vaccines and centers. There is thus an urgent need for pragmatic and pro-active approaches when educating women of child-bearing age as well as a need to advocate for an increase in the availability and affordability of immunisation facilities across the country. This poses a serious challenge to community health nurses who are saddled with provision of adequate information needed for health promotion and disease prevention across all age groups.

This is expedient because cervical cancer, when unattended to, leads to more serious complications and eventually death. Women as psychosocial beings have unique perceptions which could be modified when threatened by susceptibility to contracting cervical cancer, thus resulting in compliance.

RecommendationsIt was evident from the findings of the study that the level of

awareness of HPV vaccine was generally low. Therefore, it is necessary to have a sensitization program in place for the general public through the use of mass media. Also, if the “Health for All” by year 2015 is to be achieved in Nigeria, there is an urgent need to formulate policy which would integrate HPV vaccine into the existing National Immunization scheme at a highly subsidized rate.

The findings also underscore the importance of nurses in general and community health nurses in particular, being the primary entry into the health care delivery system and whose major role is to create awareness, help individuals at the grassroots to prevent illness and promote health by providing information of where the vaccine are readily available and providing effective follow up. Furthermore, nurses’ attitude and behavior towards sexually transmitted diseases should be such as would encourage women to enquire about their reproductive health issues. The researchers strongly advise that this research work be carried out in other parts of the country to identify other barriers to vaccination that were not addressed in this study.

Limitations of the StudyThis research was limited to women who patronized centers where

the vaccines were available in Ibadan. The scope of this study could be expanded to include adolescent boys and girls.

References

1. Schnatz PF, Markelova NV, Holmes D, Mandavilli SR, O’Sullivan DM (2008) The prevalence of cervical HPV and cytological abnormalities in association with reproductive factors of rural Nigerian women. J Womens Health (Larchmt) 17: 279-285.

2. Blair M (2004) Sexually transmitted diseases: an update. Urology Nursing 24: 6.

3. Castellsagué X, Muñoz N (2003) Chapter 3: Cofactors in human papillomavirus carcinogenesis--role of parity, oral contraceptives, and tobacco smoking. J Natl Cancer Inst Monogr 20-28.

4. de Sanjosé S, Valls I, Paz Cañadas M, Lloveras B, Quintana MJ, et al. (2000) Human papillomavirus and human immunodeficiency virus infections as risk factors for cervix cancer in women prisoners. Med Clin (Barc) 115: 81-84.

5. Cummins J, Ho Mae-Wan (2009) The HPV vaccine controversy. Science in Society 42: 15-20.

6. Lowy DR, Schiller JT (2006) Prophylactic human papillomavirus vaccines. Journal of Clinical Investigation 116: 1167-1173.

1. Awareness of where the vaccine is available

Frequency Percent Cumulative %

a. Yes 70 39.1b. No 94 52.5 91.6c. No response 15 8.4 100.0Total 179 100.02. Women who had taken the vaccine Frequency Percent Cumulative %a. Yes 37 20.7b. No 133 74.3 95.0c. No response 9 5.0 100.0Total 179 100.03. The vaccine is too expensive Frequency Percent Cumulative %a. Agreed 41 22.9b. Disagreed 45 25.1 48.0c. Undecided 62 34.6 82.6d. No response 31 17.3 100.0Total 179 100.04.My culture or religion prevents such a vaccine


a. Agreed 4 2.2b. Disagreed 129 72.1 74.3c. Undecided 28 15.6 89.9d. No response 18 10.1 100.0Total 179 100.05. There is adequate information about HPV by nurses


a. Yes 41 22.9 b. No 120 67.0 89.9c. No response 18 10.1 100.0Total 179 100.06. Women who think the vaccine can stop fertility


a. Yes 56 31.3b. No 105 58.7 90.0c. No response 18 10.1 100.0Total 179 10.17. Vaccination should be subsidized Frequency Percent Cumulative

percenta. Yes 142 79.3b. No 19 10.6 89.9c. No response 18 10.1 100.0Total 179 100.0

Table 3: Perception and Barriers to Vaccination.

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7. Haug CJ (2008) Human papillomavirus vaccination – reason for caution. New England Journal of Medicine 59: 861-862.

8. Hildesheim A, Herrero R, Wacholder S, Rodriguez AC, Solomon D, et al. (2007) Effect of human papillomavirus 16/18 L1 viruslike particle vaccine among young women with preexisting infection: a randomized trial. JAMA 298: 743-753.

9. Schiller JT, Castellsague X, Villa LL, Hildesheim A (2008) An update of prophylactic human papillomavirus L1 virus-like particle vaccine clinical trial results. Vaccine 26: K53-K61.

10. Cummins J (2006) Recombinant cervical cancer vaccines. Science in Society 29: 20-21.

11. Alabi O (2010) Health professionals advise women on cervical cancer vaccine. www.medscape.org/resource/cervical cancer vaccine/cme (accessed in September, 2010).

12. WHO (2009) Human papillomavirus vaccines WHO Position Paper in WHO Weekly epidemiological record 10 April 2009: No. 15, 2009, 84 117-132. Accessed at: http://www.who.int/wer/2009/wer8415.pdf.

13. Okonkwo KC, Reich K, Alabi AI, Umeike N, Nachman SA (2007) An evaluation of awareness: attitudes and beliefs of pregnant Nigerian women toward voluntary counseling and testing for HIV. AIDS Patient Care STDS 21: 252-260.

14. Ezem BU (2007) Awareness and uptake of cervical cancer screening in Owerri, South-Eastern Nigeria. Ann Afr Med 6: 94-98.

15. Bamgboye EA (2002) A Companion of Medical Statistics (1st Ed). IBIPRESS & PUBLISHING CO. Ibadan Oyo, Nigeria, pp 175- 209.

16. Kulasingam S, Connelly L, Conway E, Hocking JS, Myers E, et al. (2007) A cost-effectiveness analysis of adding a human papillomavirus vaccine to the Australian National Cervical Cancer Screening Program. Sex Health 4: 165-175.
















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eH m ea f o lth Community Medicine & Health Education · deaths in 2025 is 15,251 (Nigeria Human Papilloma Virus summary report). This clearly shows that cervical cancer is a serious