Effect of peer education on knowledge, attitude, and practice of HPV infection prevention among college students

A descriptive, quantitative interventional study was conducted among undergraduate students in a comprehensive university in Shanghai. The inclusion criteria for the participants were as follows: (i) undergraduate student and (ii) informed and voluntarily joined the study. In addition, the undergraduate students who were suspended from the university were excluded from this study. The participants were clustered into classes of medical and non-medical majors and were sampled. Medical and non-medical classes were sampled conveniently, as convenience sampling was effective to conduct and was well-suited to this short time-frame study. Consequently, 536 students from 18 classes under medical and non-medical majors in spring semester 2023 were sampled in this study.

Three outstanding students with excellent academic performance and good communication and management skills were selected by the counselor in each class at the beginning of the semester. They formed the peer educator team. The team received training from 2 instructors of Project Hope Shanghai representative office cervical cancer/HPV prevention education program. The 2-day HPV prevention peer educator training program contained theoretical and practical aspects. The instructors organized the theoretical part in lectures, including cervical cancer definition, etiology, risk factors, transmission, prevention, HPV vaccine, etc. Practical part was conducted in small groups. Peer educators demonstrated and practiced the methods on delivering knowledge, such as small group discussion, role play, debate, and buzzer game. In the following week, peer educators were required to design a 3-month cervical cancer prevention peer education plan. The plan would be assessed and approved by one instructor. In addition, peer educators’ knowledge mastery and competence on delivering knowledge were evaluated by the instructors 1 week after the training. Peer educators would be retained until they passed the evaluation session.

The rest of the students of each class were divided into 3 groups (9–11 students per group). One peer educator and one group of each class were matched. In the following 3 months, they shared, exchanged, discussed, and debated the information and knowledge about cervical cancer and HPV vaccine. The peer educator took the responsibility for organizing the time and location, guiding the process, and ensuring the accuracy of knowledge.

This survey used a self-designed “HPV Prevention Knowledge, Attitude, and Practice Questionnaire,” with a Cronbach’s α of 0.806 and an expert validity of 0.924. The questionnaire includes 2 parts: general information and HPV infection and prevention knowledge, attitude, and practice questionnaire.

(1) General information: including gender, age, major, whether heard of cervical cancer, whether heard of HPV vaccine, whether received HPV vaccine, etc.

The researchers distributed and collected questionnaires in self-study evening class before and after the peer education intervention. The purpose of the questionnaire, as well as voluntary participation and information security, was explained in advance. A total of 536 pre-peer education questionnaires were collected, and 525 post-peer education questionnaires were collected (11 students withdrew from the study due to reasons such as military service, school suspending, and voluntary withdrawal). After excluding incomplete/invalid questionnaires and those that failed to match between pre- and post-tests, 497 valid questionnaires were obtained, with an effective rate of 92.72%.

SPSS 23.0 software (IBM Corporation, Armonk, New York, United States) were utilized for data analysis. The measurement data are presented as mean ± standard deviation, and the counting data are presented as rate or constituent ratio. The comparison of counting data before and after peer education is performed using the Wilcoxon rank sum test, and the comparison of measurement data is performed using the paired sample t-test. The relationship between knowledge, attitude, and behavior is analyzed using Pearson correlation analysis, and the level of significance is α = 0.05.

This study has been reviewed and approved by the Academic Ethics and Integrity Committee of Shanghai ShanDa University in accordance with the principles outlined in the relevant national/international ethical standards (approval number. 2023009). The study has been designed to minimize potential risks to participants, and all participants have been fully informed of the purpose, methods, and potential risks and benefits of the study. Participants have been given the opportunity to ask questions and provide their consent to participate voluntarily. Confidentiality and anonymity have been ensured throughout the study, and measures have been taken to protect the privacy and dignity of all participants. The research team is committed to ensuring that the findings of this study are used responsibly and in a manner that benefits society.

The surveyed participants were aged between 18 years and 21 years, with a mean age of 19.523 ± 0.625 years. The majority were female, and medical major students were slightly higher when compared to non-medical major students. Before the peer education intervention, the proportion of students who had heard of cervical cancer was significantly higher than those who had heard of HPV vaccine. A small percentage of students did not consider peer education as a form of knowledge teaching or training. After the peer education intervention, there was a significant increase in the awareness rate of cervical cancer, HPV vaccine awareness rate, and HPV vaccination rate. The detailed data are provided in Table 1.

Before and after peer education, the correlation between the knowledge, attitude, and behavior of the study subjects regarding HPV was statistically significant (P < 0.01 or P < 0.05). The detailed data are presented in Table 2.

The study results showed that through peer education, the scores of knowledge, attitude, and behavior regarding the prevention of HPV infection among college students increased, with statistical significance (P < 0.05). College students with a medical background had higher scores in knowledge, attitude, and behavior regarding the prevention of HPV infection compared to those with non-medical backgrounds, but only the knowledge section showed statistical significance after peer education (P < 0.05). The detailed data are presented in Table 3.

Yang et al.¹³ conducted a study in 2016 on 2131 nonmedical female students in Xi’an, China, which showed that only 9.7% were aware of HPV vaccine. Lu et al.¹⁴ conducted a questionnaire survey in 2015 on 810 college students in Shanghai, which showed that only 6.42% were aware of HPV vaccine. The results of this study showed that the awareness rate of HPV vaccine among college students before peer education intervention was 49.70% (Table 1), which was slightly higher but still lower than the awareness rates of 92% and 81% among American and British women, respectively.¹⁵ With the approval of imported and domestic HPV vaccines in China, college students’ access to relevant reports and information gradually increased, which was closely related to the rise in their awareness rate. After peer education, the awareness rate of HPV vaccine among college students significantly increased, with significant

statistical significance (Table 1), indicating that peer education is efficient to a certain extent. However, the vaccination rate of HPV vaccine among college students was relatively low (2.82% before peer education and 5.23% after peer education), and the change was not statistically significant (Table 1). The peer education intervention lasted for 3 months, and it takes time for cognition to turn into action. HPV vaccine has been on the market for a short time, and its efficacy and side effects are not yet clear. The vaccine is not included in the national first-class vaccine, and the cost needs to be self-paid. The vaccine/vaccination point coverage is limited, and these factors require college students to make a cautious vaccination decision.

Table 2 shows that there is a positive correlation between knowledge, attitudes, and behaviors related to the prevention of HPV infection among college students before and after peer education intervention, with statistical significance. This is consistent with the KAP theoretical model (Knowledge, Attitude/Belief, Practice) proposed by the British scholar Koster in the 1960s.^16–18 Acquiring knowledge of preventing HPV infection is the foundation; establishing positive attitudes and beliefs for preventing HPV infection is the driving force; producing behaviors for preventing HPV infection and receiving vaccinations is the result. These three are a continuous process, and there is a close relationship between them. Peer education is an important external condition that helps and promotes college students to acquire knowledge, form attitudes, and develop behaviors.

Table 3 shows that the scores of knowledge, attitudes, behaviors and total score related to the prevention of HPV infection among college students after peer education intervention were significantly higher than those before peer education, with statistical significance. This indicates that peer education is an effective intervention method for improving knowledge acquisition, establishing positive attitudes, and promoting positive behavior trends. Peer education has been rarely used in the prevention of HPV infection and cervical cancer, but has been widely used in the prevention of AIDS and other diseases, with positive results consistent with the findings of this study.^19–22 Before peer education, the influence of major on the knowledge, attitudes, and behaviors of college students in preventing HPV infection was not statistically significant. After peer education, medical major college students had higher scores in knowledge than non-medical major college students, with statistical significance. However, there was no statistically significant difference between the 2 groups in attitude and behavior scores, indicating that medical background is helpful for college students to absorb and master relevant professional knowledge, but the influence factors of attitude and behavior are diverse and complex, and knowledge is only one of them.