Assessment of Knowledge about the Human Papillomavirus and Factors Influencing the Attitude Towards Recommended Protective Vaccinations against HPV among the Inhabitants of the Lodz Voivodeship

Background: HPV (human papilloma virus) is one of the most common viral infections and almost every sexually active person will be infected with it during their lifetime. Infection may be asymptomatic or clinically manifest causing multiple disease units. There is primary prevention available in the form of recommended protective vaccinations. Objective: To assess knowledge about the human papillomavirus and factors influencing the attitude towards recommended HPV vaccinations among the in-habitants of the Lodz Voivodeship. Material and methods: Original online survey questionnaire consisting of 20 questions. The study involved 134 participants. Results: 80.6% of the respondents knew what the abbreviation HPV means. 75.0% of them correctly identified the route of sexual contact as the route of the virus transmission. The majority, i.e., 85.1%, of those surveyed indicated cervical cancer as a disease that may be the result of HPV infection. 92.5% of respondents were aware of the existence of the HPV vaccine, while 72.9% of them were aware that it was recommended for both girls and boys. 92.3% of those who had been vaccinated in the past supported the recommended protective vaccinations, as well as 52.4% of those who had not been vaccinated, and 46.2% of those with unknown vaccination history Conclusions: Medical workers were more knowledgeable about the human papillomavirus than non-medical workers, so physicians should constantly educate their patients. People who were vaccinated in the past have a more positive attitude towards vaccination than people were not vaccinated. Information cam-paigns should be organized for the inhabitants of the Lodz Voivodeship to promote knowledge about pathogenicity, risk factors, and HPV prevention and its methods.


Background
HPV (human papilloma virus) is one of the most common viral infections and it causes a number of symptoms in both women and men [1].Almost every sexually active person will become infected during their lifetime [2].HPV is a non-enveloped DNA virus [3].There are several hundred types of the virus, and HPV infection may be asymptomatic, mildly symptomatic, or clinically overt.In most cases, self-healing occurs.Virus types with low and high oncogenic potential can be distinguished.Highly oncogenic types, which include types 16,18,31,33,35,39, 45, 51, 52, 56, 58 and 59, increase the risk of developing, among other things, cervical, anal, or vulvar cancer.HPV infection is the major risk factor for cervical cancer.HPV DNA has been shown to be present in 99.7% of cervical cancer samples, confirming a causal relationship between HPV infection and cervical cancer.On the other hand, the consequence of low oncogenic types (types 6,11,13,30,40,42,43,44) may be genital warts [2].Human papillomavirus may cause many disease units, including precancerous conditions and cervical cancer, precancerous conditions and vaginal cancer, anal cancers, cancers of the mouth, throat, tongue and palate tonsils, terminal warts, laryngeal papillomavirus, penile warts, and foot warts.The reservoir is an infected human.HPV is an epidermotropic virus -it has affinity for the epithelium.It is most often transmitted through sexual contact and skin-to-skin genital contact.It can also be transmitted vertically during childbirth from mother to child.Unlike HIV, HPV is not transmitted by blood [4].The methods of infection prevention include, among other things, renouncing sexual contacts, limiting the number of partners, and using condoms.It should be remembered that although a condom is a mechanical barrier against microbes, it does not provide 100% protection against the transmission of the virus, but it only reduces the risk of infection [2].There is a possibility of primary prevention -namely vaccination against HPV.Prophylactic vaccination is the only effective method of primary prevention of diseases associated with HPV infection.The greatest health and social benefits come from the parallel activities of primary prophylaxis, which involves the spread of HPV vaccination, and secondary prophylaxis, which involves regular cytological testing [5].Since 2023, Poland has started a universal program of free HPV vaccinations targeting both girls and boys aged 12 and 13.In Poland, two vaccines are available free of charge: Cervarix and Gardasil 9.They are administered in two doses, with an interval of 6 to 12 months [6].Cervarix is a bivalent vaccine against types 16 and 18 [7], while Gardasil 9 is a 9-valent vaccine against types 16, 18, and less common but still highly oncogenic types 31, 33, 45, 52, and 58 [8].

Material and methods
The study method comprised an original online survey questionnaire consisting of 20 questions.The study included 134 participants, 55.2% of whom were women and 44.8% of whom were men.Complete characteristics of the study group are presented in tabular form (Table 1).Inclusion criteria for the study were as follows: age between 18 and 40, residence in the Lodz Voivodeship, and informed and voluntary consent to participate in the study.Exclusion criteria included: age <18 years and >40 years, residence in other voivodeships, lack of consent to participate in the study.After entering the data collected in the surveys into an MS Excel spreadsheet, all the empirical material was analyzed.Descriptive methods and statistical inference were used to develop it.The chi 2 test of independence was used to compare the frequencies of each trait variety and to determine correlations between qualitative traits.Differences between frequencies and correlations between traits were considered statistically significant if the calculated value of the chi 2 test was greater than or equal to the critical value, which was derived from the tables for the corresponding number of degrees of freedom assuming a probability of error of p<0.05.

Results
80.6% of the respondents knew what the HPV abbreviation means.75.0% of them correctly identified the route of sexual contact as the route of transmission of the virus.In the survey, respondents were asked to identify individual diseases that they thought might be caused by HPV infection.Detailed data are shown in the graphic form (Figure 1).Most of the respondents, i.e. 85.1%, indicated cervical cancer as an individual disease that may be the result of HPV infection, while only 47.8% of the respondents were aware of the possibility of developing infection in the form of vaginal cancer, while for anal cancer the corresponding number was 41.0%, for cancer of the mouth, throat and palate tonsils -35.1%, for terminal warts -30.6%, for laryngeal papilloma -29.9%, and for warts and feet cancer -27.6%.Some respondents wrongly identified pearly lumps of the penis (18.7%) and hard ulcer (10.4%) as complications of HPV infection.Sexual contact as a route of virus transmission was indicated by 94.1% of medical workers and 68.4% of non-medical workers (Table 2).HPV-6, HPV-11, HPV-40 types as causing low-risk cancers and HPV-16, HPV-18, HPV-31, HPV-33, HPV-35 as high-oncogenic types were identified by 77.8% and 83.3% of medical professionals and 33.7% and 70.1% of those working in fields other than health care, respectively.The observed differences turned out to be statistically significant -p<0.05;chi 2 =8.978.97.2% of medics correctly indicated that HPV does not only affect people with multiple sexual partners, and 94.3% stated that condoms do not completely protect against infection.Among non-medical workers, 56.1% and 59.2% of the respondents were aware of this information, respectively.100% of medics and 89.9% of non-medics knew about the existence of primary prevention in the form of recommended immunizations.Information concerning the fact that the vaccination is recommended for both girls and boys was known to 91.4% of physicians and 66.3% of non-physicians.The recommended vaccination administration period being the age between 12 and 14 before the onset of sexual intercourse was correctly indicated by 100% of medics and 67.3% of non-medics.The observed differences turned out to be statistically significant -p<0.001;chi 2 =15.443.As many as 49.2% of the respondents indicated as false the information that most HPV infections are asymptomatic and self-medicate.This is erroneous and increases the risk of virus transmission between people unaware of a possible infection.Almost one in three respondents thought that the risk of HPV infection only occurred in people who had multiple sexual partners (32.8%), and the use of condoms protected against infection in 100% (31.6% of the respondents).Among them, there were 31.5% and 17.6% women and 45.0% and 48.3% men, respectively.Statistically significant differences between women's and men's knowledge in the field concerned the awareness that HPV does not affect only those with multiple sexual partners (p<0.05;ch 2 =7.29), the use of condoms does not fully protect against infection (p<0.05;chi 2 =14.202), and the fact that both girls and boys should be vaccinated (p<0.05;chi 2 =6.733) (Table 3).know if they had been vaccinated or not -46.2%.The observed differences turned out to be statistically significant -p<0.001;chi 2 =24.557.Therefore, it can be concluded that being vaccinated in the past is a factor that influences later attitudes toward vaccination (Figure 2).

Discussion
The human papillomavirus is a proven causative agent of many disease conditions, including serious cancers.Raising public awareness of this correlation and of how to prevent HPV infection is an important element of prevention.The results of this study show that the healthcare-related respondents from the Lodz Voivodeship had a higher level of knowledge about HPV and HPV vaccinations.A Polish study from 2021, which included students from different universities, confirmed that among medical students the level of knowledge about HPV and infection prevention was significantly higher than among non-medical students [9].Similar conclusions were drawn in the 2017 study conducted in Hong Kong [10] and Turkey.In the Turkish study it was observed that the level of knowledge in both groups was insufficient and further education is necessary [11].The study being the subject of this article showed that women from Lodz had better knowledge about the human papillomavirus than men.This correlation is confirmed by a study carried out in Brazil in 2019, in which data from young adults of both sexes were collected [12].Greater knowledge in women may be due to the fact that HPV is mainly associated with cervical cancer, although infection with this virus is a risk factor for many other cancers, including anal, oral and throat cancers [13].Moreover, an American study of 2008 showed that there is an increase in the number of diagnosed cases of non-cervical HPV-related cancers in the US.In addition, cancers of the mouth, throat and anus occur with a comparable frequency in women and men [14].Cervical cancer was the most common result of HPV infection according to the respondents, while only 35% of them associated it with oral and throat cancers.Similar results were obtained in a Dutch study of 2021, in which the need to increase the emphasis on this aspect in public education was stressed [15].Similar conclusions were reached by researchers from Brazil in a study conducted in 2022 on a group of students of the State University of Parana [16].
HPV vaccines are currently one of the most effective vaccines available.All are directed against oncogenic HPV-16 and HPV-18 types, which are the cause of most HPV-dependent cancers [17].Their effectiveness was confirmed in a 2020 meta-analysis of 14 high-income countries [18].50% of the respondents in the study reported a positive attitude towards the recommended HPV vaccination in children.The demographic factors influencing the approach to vaccination were gender, age, and educational level of the respondents.In the study conducted in Poland in 2022 it was found that HPV education and knowledge were factors influencing parents' attitudes to vaccination.There was no significant correlation between gender, age, or place of residence [19].In a 2021 Chinese study, place of residence and level of knowledge about HPV were important determinants of attitude towards vaccination [20].

Conclusions:
1. Medical workers have been more knowledgeable about the human papillomavirus than non-medical workers, so physicians should constantly educate their patients, as well as other persons from non-healthcare backgrounds, and encourage them to take the recommended protective vaccinations.2. Women were more likely to be in favor of HPV vaccine protection than men, and they were more likely to be aware of the age at which the vaccination is recommended.They were also more likely to be aware that both girls and boys should be vaccinated.3. Differences between women and men in terms of their knowledge on HPV concerned the awareness that HPV does not only affect people with multiple sexual partners, and that condoms do not fully protect against the infection.Women are better educated than men as far as knowledge on HPV is concerned; therefore, it is important to educate men in this area in order to minimize unconscious infection of partners.4. Socio-demographic factors influencing attitudes towards vaccination include gender, age, and education.The place of residence had no effect on attitudes towards the vaccination.5.People who were vaccinated in the past have a better attitude towards vaccination than people who were not vaccinated.6.People who did not know their vaccination history most often had no opinion about the recommended protective vaccinations.This may be due to the fact that there is less interest in the health situation in such people compared to people who are knowledgeable about their previous vaccinations.7. Information campaigns should be organized for the inhabitants of the Lodz Voivodeship to promote knowledge about pathogenicity, risk factors, as well as HPV prevention and its methods.

Figure 1 .
Figure 1.Disease entities which, according to the respondents, may be caused by HPV infection

Figure 2 .
Figure 2. Attitude towards recommended HPV vaccination based on past vaccination history.

Table 1 .
Characteristics of the participants

Table 2 .
Knowledge about HPV among medical and non-medical workers

Table 3 .
Knowledge about HPV among women and men