Singaporean men's knowledge of cervical cancer and human papillomavirus (HPV) and their attitudes towards HPV vaccination
Introduction
Human papillomavirus (HPV) is one of the most common sexually transmitted infections and the cause of 99.7% of cervical cancer cases [1], which is among the most frequently occurring cancers in women [2], [3]. Because HPV poses a greater threat to women's health than men's, research has focused primarily on women's awareness and knowledge of HPV. A recent review of 39 studies [4] worldwide found women's knowledge to be poor despite further studies revealing strong support for HPV vaccination [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17].
However, the risk of cancer from HPV infection is not confined to women. Although rarer, HPV also has links with penile [18] and anal cancer in men [19]. Anal HPV infection has been found in 24.8% of at least one sample of U.S. heterosexual men [20]. In addition, men's sexual behaviour plays a large role in the transmission of HPV. Those with HPV tend to report histories involving larger numbers of sexual partners than those without HPV [21]. Meanwhile, the risk of cervical cancer declines when a woman's male sexual partner has fewer relationships [22], [23], uses a condom [24], and has been circumcised [25]. Awareness among men of HPV and the risks it poses for themselves and their female partners is therefore crucial for reducing the incidence of cervical and other cancers, especially because HPV is rarely symptomatic, and men are unlikely to know if they have been infected.
As fathers, some men may play a role in deciding whether their children are vaccinated against HPV. Vaccination programs are predominantly administered to older children and adolescents because HPV vaccination is most effective before a person becomes sexually active. Whether or not parents agree to have their children vaccinated is therefore a crucial factor in controlling cervical cancer, so gauging men's attitudes and beliefs about HPV vaccination is as important as gauging those of women.
To date, little is known of men's knowledge of cervical cancer and HPV. Two population-based studies conducted in the U.K. [26], [27] found the majority were unaware of the link between HPV and cervical cancer. In a 2006 Belgian study conducted in a general medical practice [28], men rated genetic factors, smoking, and bacterial infections as more likely causes of cervical cancer than HPV. Meanwhile, a recent Australian study [29] revealed less than half of gay men had heard of HPV. Other studies were conducted among university students [30], [31], [32], [33], [34], many of which show men to have low awareness of HPV, although a recent study suggests awareness of HPV is now increasing since the introduction of HPV vaccination [35].
Most of this research, however, has not assessed men's attitudes towards HPV vaccination. Of the population-based studies, only one has done so [12]. This 2007 Australian study found 89.9% were in favour of HPV vaccination for either females or both sexes. Unfortunately, however, the study did not examine men's knowledge of cervical cancer or HPV other than to report that less than 2% were aware of the link between the two.
In the U.S., a public health education campaign, Healthy People 2010 [36], aims to reduce the proportion of people with HPV. However, the success of this and similar campaigns depend on men having knowledge of HPV and awareness of the risks posed by their sexual behaviour on the health of their sexual partners. A comprehensive survey of men's knowledge, attitudes, and beliefs with regard to cervical cancer, HPV, and HPV vaccination is therefore required to ensure campaigns are appropriately targeted and maximally effective.
Raising men's awareness of the risks of HPV is also essential for maximising HPV vaccination uptake in countries proposing to establish HPV vaccination programs. Singapore is one country where plans for a full-scale HPV vaccination program are underway. Many Singaporean women now expect their husbands to have equal involvement in raising their children [37], therefore making it increasingly likely for Singaporean men to play a role in making health decisions for their children. For this reason, men should be included when assessing Singaporean's knowledge of cervical cancer and HPV, and their attitudes and beliefs towards HPV vaccination. While a study of Singaporean women's knowledge, attitudes, and beliefs was recently conducted (M. Pitts, A. Smith, S. Croy, et al., submitted) an assessment of men is still required. This paper therefore reports a population-based study of a large, representative sample of Singaporean men.
Section snippets
Participants
A random list of households from Singapore's residential directory was first generated, and the households sent a letter informing them of the project. They were then approached by Singaporean interviewers within three days of receiving the letter, which resulted in 930 men agreeing to participate. These men included all major ethnic and language groups living in Singapore and had an average age of 34.8 years, ranging between 18 and 54.
Materials
A questionnaire from a 2007 Australian study [15] was used
Sample characteristics
Of the sample, 24.0% were aged 18–24, 24.2% were 25–34, 28.0% were 35–44, and 23.9% were 45–54. Almost half (47.3%) had a child under the age of 16 living with them, with most of these men belonging to the 35–44 (71.5%) and 44–54 (61.3%) age groups.
The vast majority of men were either Singaporean citizens or permanent residents (95.7%), with 82.0% born in Singapore, 7.6% Malaysia, 4.7% India, 2.2% China, 1.1% Indonesia, and 2.4% in one of a variety of other countries. When asked about
Discussion
Singaporean men in our sample displayed moderate knowledge of cervical cancer but poor knowledge of HPV. Only a small number had ever heard of HPV, mainly through the media, and of these, almost all had a number of misconceptions. Of particular concern was Singaporean men's lack of awareness of the fact that HPV can be transmitted through skin-to-skin contact, that it is linked with cervical cancer, and is rarely symptomatic.
Levels of awareness of HPV displayed by Singaporean men were at the
Acknowledgements
This research was supported by GlaxoSmithKline (GSK) via a grant-in-aid to Suzanne Garland at the Department of Microbiology Infectious Diseases at the Royal Women's Hospital, Melbourne, Australia. GSK had no involvement with the design or data analysis of this research. Data collection was carried out by Joshua Research Consultants, a Singaporean research organisation with experience in conducting community and health surveys.
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2010, VaccineCitation Excerpt :A recent survey of Singaporean men showed that they have moderate knowledge of cervical cancer, but poor knowledge and awareness of HPV. Although these men showed strong support for HPV vaccination, the investigators highlighted the importance of including men in education campaigns that aim to decrease the incidence of cervical cancer [21]. However, our results suggest that it may not be sufficient simply to increase public awareness of the fact that cervical cancer is caused by HPV infections: although Taiwanese mothers displayed the greatest awareness of HPV vaccination, they also had the lowest perception of risk for themselves or their daughters.