Mothers ’ Knowledge and Attitudes about HPV Vaccination to Prevent Cervical Cancers

Cervical cancer which is one of the most preventable cancers is an important public health problem worldwide, and especially in developing countries (Dochez et al., 2014; Duman; Yılmazel, 2014). Cervical cancer is the fourth most common cancer in women, with an estimated 528,000 new cases in 2012.There were an estimated 266.000 deaths from cervical cancer worldwide in 2012, accounting for 7.5% of all female cancer deaths (Globan, 2012). According to the data from Health Statistics Annual of Ministry of Health in Turkiye, it is reported that the prevalence of cervical cancer is 7.1 in 100000. (Ministry of Health Health Statistics Annual, 2012). Almost the whole cervical cancer cases are related with human papilloma virus (HPV). Human papillomavirus (HPV) infection of the genital mucosa is a common, sexually transmitted condition and there is now conclusive evidence for its role in the aetiology of cervical cancer (Marlow et al. 2007; Dochez et al., 2014). Human papilloma virus family has 120 types 40 of which cause anogenital infections. (Ozan et al., 2011). Although most infections are asymptomatic and clear on their own, persistent genital HPV infection is associated with several sequelae, including cervical cancer in women

Two forms of vaccines have recently been approved for use for the primary prevention of cervical cancer (Devereaux Walsh et al. 2008;Drug and Food Administration, 2014). The quadrivalent vaccine also prevents vaginal, vulvar, and anal dysplasia as well as genital warts, and is also indicated for males. Advisory Committee on Immunization Practices (ACIP) currently recommends vaccination of females and males aged 11 to 13, with catch up vaccination for females aged 13 to 26. (Advisory Committee on Immunization Practices 2010). In Turkey, the HPV vaccine has been used since April 2007 (Yılmazel and Duman, 2014).
There are many factors effecting the family's approval of vaccination for their kids and its application. Introduction of the HPV vaccine has proceeded slowly in many countries because of low knowledge about cervical cancer, high vaccine cost, and cultural preferences surrounding vaccinating young girls (Tsui et al., 2009;Madhivanan et al., 2014). Studies have shown that ageat-vaccination is an important factor in parental decisionmaking about immunizing daughter against HPV infection (Marlow et al., 2007;Madhivanan et al., 2014).
The aim of this study was to determine mothers' who have 0-to 18-year old children, knowledge and attitudes about the HPV vaccination.

Materials and Methods
This descriptive and correlational study was approved by the Ethical Board in Sakarya University and study started after receiving approval from related local authorities. Study was conducted between May-June 2014. Universe of the study consisted of all the mothers who applied to pediatric outpatient clinic at two state hospitals in Sakarya province and who have children between 0-18 years-old. Sample of the study consisted of 799 mothers who agreed to participate. The participation criteria; mothers who were over 18 years old and have healthy children between 0-18 years old, who have no communication problems and who were voluntary to participate in the study. The mothers of the children in Paediatric ICU and the ones who have disabled children were not included in the study.
The data were collected via a "Personal Information Form" which included 30 questions that were prepared by the researchers themselves in line with the literature (Madhivanan et al., 2014;Duman and Yılmazel, 2014). Personal Information Form includes items on age, educational status, economical status, occupation, mother's working status and questions regarding knowledge and attitudes about the HPV (if they knew about the vaccination, when and to whom the vaccination was performed, etc.).
The participating mothers were informed of the purpose of the study and the methods to be used and signed an informed consent statement. The data were collected by face to face interviews with the mothers.
Chi-square test was used to compare between the mothers' knowledge and attitude towards HPV and their sociodemographic characteristics. A p<0.05 was considered statistically significant. Analyses were performed using commercial software (IBM SPSS Statistics 20, SPSS Inc. An IBM Corp., Armonk, NY)

Results
The average age of the mothers participated in the study was detected to be 32.0±6.52 (min=18, max=55). A total of 63% of the mothers were primary school, 25.7% were high school and 11.4% were university graduates. 84.5% of the mothers stated that they did not work and 69.6% stated that they had a medium level income. A total of 42.9% of the mothers had 2 children who were alive. Of the mothers who had children between the ages of 0-18, a total of 27.2% had daughters, 26.7% had sons and 46.2% had both daughters and sons (Table 1).
It was found out that a total of 88.1% of the mothers (n=704) had no information about HPV, 73.7% (n=589) did not know how the infection was transmitted and 83.5% did not have any information on HPV vaccination. A total of 27.1% (n=35) of 132 women who declared that they knew about the vaccination, stated that they learned from a health staff, 61.2% (n=79) stated that they learned from communication tools like television, radio, newspaper and internet, and 11.6% (n=15) learned from people like friends or relatives. It is found out that 83.2% of the mothers did not know at what age vaccination was applied and 84.1% did not know to whom it was applied. A total of 0.7% of the mothers who had daughters were found out to be vaccinated against HPV, 44.3% of the mothers who had sons were found out to be hesitant about being vaccinated or not.
It was found out that there was an advanced level of statistically significant difference with respect to mothers' knowledge about HPV (p<0.001), transmission of HPV (p<0.001), HPV vaccination (p<0.001), the sex to which vaccination is applied (p<0.001), and about the age vaccination is applied at (p<0.001) according to the mothers' education levels ( Table 2).
According to the economic situation of mothers, there was a statistically significant difference between knowledge about HPV (p<0.001), HPV vaccination (p<0.001), and the sex to which vaccination is applied

Discussion
This is a study which aims to detect the knowledge and attitudes of mothers towards HPV vaccination that intends to avoid cervical cancers in Sakarya district of Marmara Region in Turkey.
It was found out that a majority of, 88.1% of mothers did not have any knowledge about HPV. In a study conducted by Marlow et al. (2007), it was seen that 72.8% of the mothers who have daughters between the ages of 8-14 had never heard of HPV before. In Sanders Thompson et al. (2011)'s study, only 124 (62%) participants had heard of HPV. Most mothers (27.7%) hadn't heard of HPV previously (Berenson et al. 2014). A study by Tozzi et al.(2009) in Italy revealed that 33.5% of the mothers who have daughters between the ages of 10-12 had never heard of HPV previously. In the studies in Turkiye, it is seen that 55% of the mothers had never heard of HPV before (Dursun et al. 2009) and 66.4% of the mothers had no knowledge about HPV (Ozan et al. 2011). In Ghojazadeh et al (2012)'s study, 76% of parents said that they hado no information about HPV.
In this study, 83.5% of the mothers stated that they had no knowledge about HPV vaccination. In the studies conducted it is seen that 53.7% of the mothers (Bulbul et al., 2013), 55.4% of the mothers (Ozan et al., 2011), 50.7% of the mothers (Berenson et al.2014) and 42.3% of the mothers (Pınar et al., 2010) had no knowledge about HPV vaccination. In California, Robitz et al. (2011) stated that 45.7% of the families had never heard of vaccination previously. In Kruiroongroj et al (2014)'s study, majority of the respondents (70%) were aware of the HPV vaccine.
Of the 132 people who expressed that they knew about vaccination, 27.1% (n=35) stated that they learned about it from a health Professional, 61.2% (n=79) of them learned it from communication tools like television, radio, newspapers or internet, 11.6% (n=15) learned it from friends or relatives. In a study by Tozzi et al. (2009), 50.2% of the ones who know about HPV stated that they learned it from a doctor, 45,8% stated that they learned from television, radio or internet, 4.1% stated that they learned from friends or relatives. In their study, Madhivanan et al. (2014) stated that 85% of the families learned from television, 79% learned from newspapers and radio, 43% learned from the internet and 86% learned from the doctors. In Robitz et. al.(2011)'s study, 69.2% of the families replied "no" to the question "did any doctor or health agency during last year suggest that your daughter should be vaccinated against HPV?". In Ghojazadeh et al (2012)'s study, parents' 42% claimed that they had obtained such information by studying medical resıources and 36% from Internet and friends. In Kruiroongroj et al (2014)'s study, Tv/radio, newspapers/magazines (88%) were major information, followed by hospital /health care providers (66%).
Prophylactic vaccines against human papillomavirus (HPV) are expected to be available for public use by 2007 and likely will be targeted to preadolescent children. Parental acceptance of these vaccines will be critical for their success (Dempsey et al., 2006). 0.7% of the mothers with daughters were detected to have HPV vaccination while 44.3% of the mothers with sons were found out to be hesitant about HPV vaccination. In the study by Sanders Thompson et al. (2011), it is seen that only 16.5% of the girls were vaccinated against HPV. A study in Los Angeles County, 24.6% of parents reported that their daughters had received at least 1 dose of HPV vaccine (Robitz et al. 2011). In a study by Ozan et al. (2011), 42% of the mothers had no idea about recommending the vaccination to their daughters, and 58.9% had no idea about recommending it to their sons. Devereaus Walsh et al. (2008) stated that the majority of study participants believed that boys should be vaccinated as well as girls (91.2%). In the study by Kılıc et al. (2012) 45.5% of the mothers was willing to have their daughters vaccinated aganist HPV but most of mothers (84.1%) did not want this vaccination as they did not have sufficient knowledge about vaccine.
Mothers have been shown to be highly involved in their children's healthcare decisions, especially with regards to HPV vaccination (Berenson et al. 2014). In this study there is a significant correlation between the mothers' education level and their knowledge about HPV. It is seen that the higher education level a mother has, the more knowledge she has about HPV (Table 1). In the studies, it is clear that there is a significant correlation between mothers' education levels and their knowledge on HPV and this shows a paralellism with our study (Ozan et al., 2011;Ghojazadeh et al 2012 ).
In our study, there is a significant correlation between the mothers' education level and their knowledge about HPV vaccination. In the study by Bulbul et al. (2013), it is seen that there is a correlation between the mothers' educational status and their methods to avoid from cervical cancers, 81.9% of the mothers are stated to use vaccination as a protective method. About the mothers' education levels and their knowledge about HPV vaccination, the studies by Sanders Thompson et al. (2011) andPınar et al. (2010) also suggest that there is a significant correlation. However, the study by Ozan et al. (2011) states that there is no significant difference. According to mothers' economic conditions, there is no significant correlation between their knowledge about HPV. However, there is a significant relationship between a high income and the mothers' awareness of HPV (Sanders Thompson et al. 2011).
The limitation of this study is the fact that the results of this study include the data of Sakarya district only, so it cannot be generalized for Turkey. Similar studies for varied populations in Turkey should be performed.
As a result of this study, it is shown that mothers in a wide range do not have any information about HPV and HPV vaccination. The ones who have some information about the subjects state that they learned about the subject from televisions, radios, newspapers or the internet. Getting knowledge from the health professionals is of a small extent. Based on this result, it can be suggested that doctors and nurses are informed about this situation and mothers are trained by health professionals on this subject. The attempts to protect from this disease will be more successful if particularly mothers' awareness on this subject is raised.