Awareness, attitudes and vaccination intentions regarding cervical cancer and HPV among healthcare workers

2.1 Study type

A cross-sectional and descriptive study was carried out either by online or face-to-face administration of a 55-question survey form, which took approximately 30 minutes to complete.

2.2 Study participants

The study included participants aged 18–49 years who were employed as doctors, nurses or medical secretaries at Gaziantep University Hospital. To be eligible, participants were required to provide informed consent and complete the questionnaire completely. Individuals who did not meet these criteria, did not provide consent or submitted incomplete questionnaire form were excluded from the study. The sample size was calculated to be 324, based on a 95% confidence interval, a 5% margin of error and an assumed response rate of 50%.

After obtaining the approval from the local ethics committee (Decision No: 2024/338 Date: 23 October 2024) and the necessary permissions from the chief physician of the Gaziantep University Hospital, the study was started on 12 November 2024. Data collection concluded on 06 December 2024, upon reaching the target of 324 participants as determined by the power analysis.

2.3 Questionnaire

The survey form was developed by researchers after comprehensive review of the literatures, and using two scales validated in the Turkish language. The online survey was conducted online, free of charge through Google Forms. During both the online and face-to-face applications, the informed consent form was presented to the participants and only those who provided consent completed the questionnaire.

The survey form consisted of three parts. In the first part, socio-demographic characteristics of the participants were identified using nine questions. These questions covered age, sex, occupation, department, economic status, marital status, number of children and their age and sex. Additionally, the last 5 questions in this section explored participants’ history of genital disease, awareness of cost-free HPV screening, and their vaccination status or plans to prevent HPV.

In the second part, the Cervical Cancer Knowledge Scale was used that comprises of eight items. Each correct answer was given 1 point and the total score varies between 0–8. Participants answered to the questions with “Yes”, “No” and “Don’t know”. The “Don’t know” option was included among the answers to prevent random responses. The Turkish validity and reliability of this scale were established by Ergöz Aksoy and Bilgiç [4].

The final section employed the HPV Knowledge Scale, which includes 33 items divided into four subscales: Subscale 1 (SS1), consisted of 16 questions about knowledge of HPV; Subscale 2 (SS2), comprises of 6 questions about HPV testing; Subscale 3 (SS3), consisted of 5 questions about the knowledge of HPV vaccine protection; and Subscale 4 (SS4) composed of 6 questions about knowledge of HPV vaccinations. Participants responded to each item with “Yes”, “No” or “Don’t know”. Correct answers were scored as “1”, while incorrect answers and “Don’t know” responses were scored as “0”. The total score obtained ranges from 0 to 33, with higher score indicating a high level of knowledge about HPV screening tests and the HPV vaccine. The Turkish validity and reliability of the HPV knowledge scale were confirmed by Demir Bozkurt and Özdemir [11].

2.4 Statistical analysis

Statistical analysis methods such as descriptive statistics, independent samples t-test, and one-way analysis of variance (ANOVA) were applied to evaluate the relationships between participants’ HPV and Cervical Cancer Knowledge Levels, awareness and attitudes. Additionally, the relationships between awareness levels of different demographic groups were examined using correlation analysis.

The collected data were analyzed using the IBM SPSS Statistics 26.0 (Armonk, NY, USA). For descriptive measures, the minimum, maximum, mean, standard deviation, skewness and kurtosis coefficients were calculated. The assumption of normal distribution was evaluated by ensuring that the skewness and kurtosis coefficients were between -3 and +3. Parametric tests were applied to variables that met the normality condition, while alternative analysis methods were used for variables that did not.

Independent samples t-test and ANOVA were used to compare awareness scores across various demographic variables such as age groups, gender, profession, economic status, marital status and number of children. The relationships between HPV awareness and Cervical Cancer Knowledge Levels were assessed using the Pearson correlation coefficient.

Group analyses were conducted to investigate differences in knowledge and awareness based on HPV vaccination status, familiarity with HPV testing and Cervical Cancer Knowledge Levels.

3.1 Demographic characteristics and mean score

The study analyzed the cervical cancer knowledge and HPV awareness levels among 324 healthcare workers. Of the total participants, higher number (58%) belonged to age-group 25–34 years and higher percentage (70.1%) were female. Professional doctors and nurses each constituted 44.8% of the total participants, while medical secretaries represented 10.5% of the study population. Economic status analysis revealed that 43.2% had equal income and expenses, while 30.2% had less income than expenses. In terms of marital status, 48.8% were married and 64.5% did not have children.

Participants exhibited a mean cervical cancer knowledge score of 6.02 (SD = 2.19) on an 8-point scale, indicating a moderately high awareness level. The HPV Knowledge Scale score averaged 19.84 (SD = 7.90) out of 33, reflecting a moderate awareness level (Table 1).

Key variables showed significant variations:

1. Awareness of HPV: 67.9% of participants were aware of HPV, but only 4.1% had been vaccinated against it.

2. HPV Testing Knowledge: Awareness of HPV testing scored an average of 3.10 (SD = 1.92) on a 6-point scale, reflecting moderate understanding.

3. HPV Vaccine Awareness: Awareness of HPV vaccination was moderate, with a mean score of 3.37 (SD = 1.61) on a 5-point scale.

3.2 Knowledge score across different age-group

Significant differences in knowledge and awareness were observed across different age-groups. Participants aged 25–34 had the highest HPV awareness and knowledge, with a mean HPV Knowledge Scale score of 21.75 (SD = 7.70). Awareness scores were lower in the groups aged 24 and below (mean = 17.47, SD = 5.86), and 35 and above (mean = 17.00, SD = 8.38) (Table 2).

3.3 Knowledge score across different profession

Doctors displayed the highest cervical cancer and HPV knowledge levels (mean cervical cancer score = 6.96, SD = 1.58; HPV Knowledge Scale = 25.59, SD = 4.60). Nurses and medical secretaries scored significantly lower, with medical secretaries having the least awareness (mean HPV Knowledge Scale score = 9.74, SD = 7.88). This disparity emphasizes the need for comprehensive training for non-physician staff (Table 3).

3.4 Knowledge score across groups with different vaccination status

Vaccinated individuals exhibited higher knowledge levels (mean cervical cancer knowledge score = 6.85, SD = 1.90) compared to those planning to vaccinate (mean = 6.18, SD = 1.91) and those not planning to vaccinate (mean = 5.59, SD = 2.42). Awareness of free cervical HPV screening was strongly associated with higher knowledge and vaccination rates (Table 4).

Only 1.2% of participants planned to vaccinate their sons, while 17.9% intended to vaccinate their daughters. Awareness was significantly higher among those planning to vaccinate both genders (mean HPV Knowledge Scale = 22.42, SD = 6.92) compared to those not planning any vaccination for their children (mean = 16.18, SD = 8.06) (Table 5).

Positive correlations were identified between cervical cancer knowledge and HPV awareness scores (r = 0.655, p < 0.001). The strongest correlations existed between having heard of HPV and HPV Knowledge Scale scores (r = 0.942, p < 0.001).

Despite moderate levels of awareness, only 45.2% of participants expressed intentions to vaccinate, revealing a significant gap in translating awareness into action. The limited awareness among medical secretaries highlighted the need for targeted interventions.

4.1 Differences between age groups

The study identified age as a significant factor influencing HPV awareness and knowledge. Participants in the age-group 25–34 years had higher HPV awareness and knowledge scores, with an average score of 11.85 for having heard of HPV (PT1) compared to other age groups. This group also stood out in both subscales related to knowledge about HPV testing (PT2) and awareness of HPV vaccination (PT3) (Table 2). These findings are consistent with the results reported by Deguara et al. [7], who observed that women aged 25–35 exhibited a more positive attitude toward HPV awareness, cervical cancer screening and vaccination. These findings suggest that information on preventive health services, such as HPV vaccination, is generally more effective in this age group. It also suggests that specific campaigns should be organized to increase health awareness among younger and older individuals.

4.2 Differences between professional groups

Another important finding of this study is the significant difference in knowledge and awareness between professional groups. Physicians scored significantly higher than nurses and medical secretaries on all knowledge and awareness variables. For example, physicians have the highest mean score of 6.96 for cervical cancer knowledge. In contrast, nurses and medical secretaries had lower mean scores of 5.62 and 3.74 points, respectively (Table 3). Similarly, physicians stand out as the group with the highest level of awareness in variables such as having heard of HPV (PT1), and knowing about HPV testing (PT2). A study by Karasu et al. [12] among nurses in Istanbul, Turkey, showed the knowledge level of nurses to be 6.7 out of 10 aligning with the findings of this study.

The low knowledge score observed among professional groups such as nurses and medical secretaries highlight a critical issue, given their direct interaction with the public. The Cervical Cancer Knowledge Scale, validated in Turkish by Ergöz Aksoy and Bilgiç (2024), has proven to be an effective tool for assessing awareness levels [4]. The results of our study suggest that groups with low scores, particularly nurses and medical secretaries, require targeted educational interventions.

This difference between professional groups underscores the importance of providing comprehensive health education to all healthcare workers, not just physicians. The low level of knowledge among medical secretaries may be due their limited access to direct health education on these subjects. These findings highlights the need to develop regular training programs to increase the knowledge of all health care workers.

Keten et al.’s [13] study on teachers found low awareness and knowledge of HPV and the HPV vaccine, with only 38.4% having heard of HPV and 25.7% aware of the vaccine. This study stated that this situation was due to reliance on the information from superficial sources such as the Internet and television. Similarly, our study found limited HPV awareness among healthcare workers. While 67.9% of participants reported being aware of the HPV vaccine, the vaccination rate was strikingly low at only 4.1%. These results suggest that lack of knowledge may contribute to vaccine hesitancy. Given that less than half of the participants were considering vaccination, it is clear that public health campaigns will play a critical role in overcoming these reservations [13]. In particular, informing community leaders such as teachers and health workers can be effective in raising general awareness.

4.3 The relationship between HPV vaccination and knowledge

Vaccination plays an important role in the prevention of HPV and cervical cancer. HPV vaccines have demonstrated significant success in reducing the incidence of cervical cancer by effectively targeting high-risk HPV types. For example, a 90% reduction in genital warts and high-risk HPV infections has been reported in countries where HPV vaccination has been introduced [13]. Despite these successes, knowledge gaps and trust issues remain among the general public regarding HPV vaccination. Individuals who had received the HPV vaccine were found to have a higher level of knowledge than those who plan to receive the HPV vaccine or those who had no intention in receiving the vaccine. The results of our study showed that the mean cervical cancer knowledge score was 6.85 for vaccinated individuals, 6.18 for those planning vaccination and 5.59 for those not planning vaccination (Table 4). Similarly, awareness of HPV vaccines (PT3) and knowledge about current HPV vaccines (PT4) were highest among vaccinated participants.

These finding show that the decision to receive HPV vaccine is directly related to the level of knowledge. Existing literature also shows that low awareness has a negative impact on HPV vaccination rates. A study conducted by Deguara et al. [7] (2020) in Malta reported that low HPV awareness decreased vaccination rates. Similarly, a study carried out at the University of North Carolina revealed that while 37% of men were considering HPV vaccination, only 63% were aware of the vaccine’s existence [14]. These studies underscore the critical role of education and awareness in improving HPV vaccination rates.

Another study conducted in Turkey found that only 4% of male nurses were vaccinated against HPV. Similarly, our study reported that individuals with a low level of knowledge were less likely to be vaccinated against HPV [12]. The low level of knowledge among individuals who do not plan to be vaccinated highlights the need for special awareness campaigns targeting such group. The literature supports the effectiveness of such campaigns in improving vaccination rates. For example, the WHO’s “90-70-90” strategy emphasizes that raising awareness is critical to achieving vaccination goals [10].

Our findings regarding childhood vaccination intentions align with trends reported in the literature. In our study, only 1.2% of participants planned to vaccinate their sons, while 17.9% reported planning to vaccinate their daughters. Prioritizing girls for HPV vaccination is often emphasized in the literature [14, 15, 16]. Given that HPV can cause serious health problems in both sexes, there is a need for educational efforts to promote vaccination for boys as well [6].

4.4 Strengths, advantages and limitations of the study

This study has several strengths that increase its validity and relevance in understanding healthcare professionals’ knowledge, attitudes and practices regarding cervical cancer and HPV. First, the inclusion of different groups of health professionals, such as doctors, nurses and administrative staff, allows for a comprehensive analysis of differences across professional roles. Second, the use of validated questionnaires ensures the reliability and comparability of the data collected. Third, the study fills a critical gap in the literature by focusing on the intentions and practices of health professionals, which plays a fundamental role in increasing public awareness and immunization rates. Finally, by highlighting specific knowledge gaps and barriers, the study provides actionable insights for designing targeted education and intervention programs.

Despite these important findings, the study has also some limitations. Firstly, the findings may not be generalizable because the study was conducted in a single health center. Secondly, due to the cross-sectional design, cause-and-effect relationships between HPV awareness and vaccination behavior could not be assessed. Future research should address these limitations by collecting data from different regions and larger, more diverse sample groups. Addressing these limitations will further contribute to the development of effective interventions aimed at increasing HPV awareness and vaccination rates.