Accepted Manuscript Knowledge of Human Papillomavirus and Acceptability to Vaccinate in adolescents and young adults of Moroccan population Yassine Zouheir, Samira Daouam, Salsabil Hamdi, Abdelaaziz Alaoui, Taoufiq Fechtali PII:
S1083-3188(15)00374-5
DOI:
10.1016/j.jpag.2015.11.002
Reference:
PEDADO 1923
To appear in:
Journal of Pediatric and Adolescent Gynecology
Received Date: 24 June 2015 Accepted Date: 12 November 2015
Please cite this article as: Zouheir Y, Daouam S, Hamdi S, Alaoui A, Fechtali T, Knowledge of Human Papillomavirus and Acceptability to Vaccinate in adolescents and young adults of Moroccan population, Journal of Pediatric and Adolescent Gynecology (2015), doi: 10.1016/j.jpag.2015.11.002. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT 1
Knowledge of Human Papillomavirus and Acceptability to Vaccinate in adolescents and young
2
adults of Moroccan population.
3
Yassine Zouheir 1, Samira Daouam 2, Salsabil Hamdi 1, Abdelaaziz Alaoui 3, Taoufiq Fechtali 1
4
1
5
Technics, Mohammedia, Hassan II University, Morocco. 2 Independent researcher, Casablanca,
6
Morocco; 3 Laboratory of Biotechnology, Valorisation and Protection of AgroResources, Faculty of
7
Science and Technology, Cadi Ayyad University, Marrakech.
8
The corresponding author: yassine zouheir, E-mail address: [email protected].
9
Abstract
SC
RI PT
Laboratory of Neurosciences, Integrated diseases and natural Substances, Faculty of sciences and
The human papillomavirus (HPV) infection is necessary cause of 99.7% of cervical cancer. Vaccines
11
can prevent up to 70% of the cervical cancer caused by HPV 16 and 18. The present study was
12
designed to define the knowledge of HPV and HPV vaccine acceptability among Moroccan youth. A
13
nationwide anonymous questionnaire with a sample of 688 adolescents (12-17 years) and 356 young
14
adults (18-30 years) was organized, that asked about HPV, origin of cervical cancer, Pap test and
15
acceptability of HPV vaccine. Data analyzed by using univariate and multivariate logistic regression
16
method. Overall, a low frequency (20%) of HPV knowledge was observed among studied population.
17
A multivariate model analysis showed that age, educational level and heard of Pap test remained
18
significantly associated factors with HPV knowledge. Additionally, only (27%) of participants were
19
willing to accept HPV vaccination. Highest acceptability was observed among young adults compared
20
to adolescents (46.6% vs 16.9%). Sixty two percent of males accepted the HPV vaccine compared to
21
only 20.4% of females. Educational level, type of school and knowledge of Pap test were associated
22
factors to HPV vaccine acceptability by multivariate model analysis. The present study showed a low
23
level of HPV knowledge and HPV vaccine acceptability among Moroccan youth. Promoting activities
24
and sensitization are required to maximize public awareness in the future. This objective can be
25
achieved by using media, active efforts by healthcare providers, and introducing of the sexual
26
education in schools program.
27
1. Introduction
28
Cervical cancer (CxCa) rates third as the most common cause of cancer among women worldwide.
29
With an annual incidence of more than 527,000 new cases (Age-standardized incidence rate (ASR): 14
30
per 100,000) and an annual mortality rate of 265,653 (ASR: 6.8) 1. Human papillomavirus (HPV) is
31
estimated to play an etiologic role in 99.7% of CxCa worldwide. Approximately 5.2% of all cancers
32
worldwide are attributed to HPV infection 2, 3. More than 70% of these cancers are caused by HPV 16
33
and HPV 18 genotypes 4.
AC C
EP
TE D
M AN U
10
1
ACCEPTED MANUSCRIPT In contrast to other developing countries in the world, the region of North Africa (NA) shows a
35
general low incidence of CxCa (ASR: 6.6). The availability and quality of the data are very different
36
from one country to another. Available data indicated that in Algeria, CxCa incidence ranks second
37
after breast cancer and third after breast and colorectal cancer in Tunisia, no data from Libya were
38
obtained. However, in Egypt, CxCa incidence/mortality data have been most extrapolated from limited
39
registries and could give a false impression that CxCa is not a major health issue 1, 3.
40
In Morocco, CxCa is considered as a major public health problem and it is the second most common
41
cancer among women after breast cancer with 2258 new cases and 1076 deaths each year
42
approximately 1. The incidence of CxCa could be much higher than reported, because published data
43
are limited to number of cases registered in some oncology centers in the absence of a national cancer
44
registry 5. The initiation of a National Cancer Control Plan, have started in 2010 to implement
45
organized screening programs using for CxCa detection 6. Two published studies focused on two
46
different regions of Morocco found a high HPV prevalence in women with normal cytology. The first
47
one was conducted in Ibn Sina Hospital, Rabat and showed a HPV prevalence of 15.8% in 2010.The
48
second study carried out at University Hospital of Fes in 2012, the HPV prevalence was 42.5%
49
None of the countries of this region has presently a National Organized CxCa Screening program;
50
Morocco and Tunisia are in the process to create such organization which can explain the highest HPV
51
prevalence in Morocco.
52
Two prophylactic HPV vaccines, Gardasil® (Merck&Co.,White house Station, NJ, USA) and
53
Cervarix® (GlaxoSmithKline Biologicals, Rixensart, Belgium) were approved in the United States
54
and Europe, respectively, and have been introduced in more than 100 countries worldwide to offer
55
protection against HPV types 16 and 18, which are responsible for the majority of CxCa [1]. The HPV
56
vaccine was licensed in Morocco since 2008 to reduce the incidence of HPV. The HPV vaccine cost
57
about $147 US (price of three-dose) constitutes approximately half a month’s income for 40% of
58
Moroccan families. In the absence of any state-funded vaccination program, it is beyond the means of
59
many people 9. The Moroccan national immunization program provides the vaccines against six
60
vaccine preventable diseases, including tuberculosis, diphtheria, pertussis, tetanus, polio and measles.
61
Adding HPV vaccine to the current national immunization program still a future perspective 10. The
62
efforts provided by the Lalla Salma Association led to the introduction of the HPV vaccine which
63
enabled the Expanded Program on Immunization (EPI) to immunize girls beginning at the age of 11.
64
This foundation was founded and headed by Princess Lalla Salma in 2005, dedicated to cancer
65
Prevention and treatment. The foundation has done Epidemiological research on HPV and is
66
supporting development of a large cervical cancer screening program. Various plans are being
67
introduced to prevent and control HPV infections which is a key advocate for HPV immunization 11.
68
The Centers for Disease Control and Prevention (CDC) reported that the HPV vaccination is
7, 8
.
AC C
EP
TE D
M AN U
SC
RI PT
34
2
ACCEPTED MANUSCRIPT 69
recommended for girls aged 13 through 26 and for boys aged 13 through 21. Ideally before beginning
70
sexual activity 12. Concerning the safety of the HPV vaccine, many studies including tens of thousands
71
of people worldwide showed no serious side effects, and confirmed the vaccine's efficiency. CDC and
72
the Food and Drug Administration (FDA) continue to control vaccine safety
73
the HPV vaccine by parents was recently studied in Morocco (2014). Responses showed very low
74
knowledge of both HPV infection (4.7%) rates and the HPV vaccine (14.3%). The acceptance of the
75
vaccine was low among mothers (32%) and fathers (45%), and none of the participants had vaccinated
76
their daughter(s) against HPV 16. The level of HPV knowledge and of the HPV vaccine acceptance
77
were different worldwide, some countries showed a low level, other exhibited a high one 17-20. To date,
78
there is an absence of data concerning the overall awareness of HPV and the acceptance of the HPV
79
vaccine among adolescents and young adults aged 12-30 in Morocco. Despite the high prevalence of
80
HPV infection among Moroccan women and the availability of a prophylactic HPV vaccine, we
81
expect a low level of HPV awareness and vaccine acceptability among adolescents and young adults
82
due to socio-religious, cultural barriers and non-introduction of the vaccine in EPI. So, the present
83
study was designed to outline the HPV knowledge level, the acceptance of HPV vaccine and their
84
factors associated among adolescents and young adults in Morocco.
85
2. Materials and methods
86
2.1. The study setting:
. The acceptance of
M AN U
SC
RI PT
12-15
The study was conducted from January 2014 to June 2014 at seven different regions across Morocco.
88
The studied regions were selected randomly. The capital of each region was included in the study for
89
the reason of its developed economy and high level of its population (Table1).
91
2.2. Study design
2.2.1. Study participants
EP
90
TE D
87
In the absence of any data about the HPV knowledge and acceptability of vaccine among Moroccan
93
youth, we targeted age groups for which vaccination is supposed to have been. Among 1290 subjects
94
aged between 12 and 30 selected randomly to participate in this study, 1044 subjects (688 adolescents
95
and 356 young adults) were accepted to participating and 246 were clearly refused (Figure 1). The
96
adolescents and young adults groups were randomly selected from schools and work or universities,
97
respectively. The variability of this population aimed to have a representative sample of different
98
economic, cultural and ethnic categories within the Moroccan society. Only unmarried participants
99
were retained in the final analysis, respecting the average age of marriage (29.5 years) indicated by the
100 101
AC C
92
high commission plan in 2004 in the urban area 21. 2.2.2. Study instruments 3
ACCEPTED MANUSCRIPT Two methods were adopted to collect data in this study: first one was the face to face interviews, the
103
second involved completing an electronic version of the questionnaire and forwarding it to the
104
corresponding author. The electronic form was considered as an alternative method when the
105
participants were not available or have a timid character (30 participants: 21 young adults and 9
106
adolescents). Participants were interviewed with a set of standard questionnaires about their socio-
107
demographic and cultural data (age, gender, educational level, private or public school). The
108
knowledge of HPV and HPV vaccine was assessed by using the questions: ‘have you ever heard about
109
HPV?’, ‘do you know the origin of cervical cancer?’, ‘do you know that HPV can infect both males
110
and females?’, ‘have you ever heard of a Pap test?’, ‘are you aware that a HPV prophylactic vaccine
111
exists?’. In addition, the acceptability of an HPV vaccine was studied by the following questions:
112
‘would you be willing to be vaccinated against HPV?’, ‘have your parents ever recommended the
113
vaccination against HPV?. The questionnaire was divided in three parts: (1) socio-demographic
114
characteristics of the participants, (2) knowledge of CxCa and HPV infection, and (3) acceptance of
115
HPV vaccination.
SC
2.2.3. Data Collection
M AN U
116
RI PT
102
117
The questionnaire was designed by researchers. Questions were based on a previously published
118
questionnaire in the literature
119
the interviewee’s preference, and took place at school, university or work again as chosen by the
120
participant.
121
To evaluate the possibility and acceptability of this study in a conservative society, and verify clarity,
122
correct wording the questions, pilot tests were performed for the baseline and follow-up surveys (n =
123
10, n = 10, respectively tow times). After these pre- tests some questions were eliminated to adapt the
124
study to our society (conservative Society and Islam religion too forbids sex before marriage).
EP
TE D
. The interviews were conducted in French or Arabic, according to
2.2.4. Ethical considerations
AC C
125
16, 22
126
All procedures performed in this study were in accordance with the ethical standards of the national
127
research committee and with the 1964 Helsinki declaration and its later amendments or comparable
128
ethical standards. The informed consent form was bound together with the questionnaire when it was
129
handed out to them. After selecting Adolescents group from class lists in each school, invitation
130
letters for the baseline interview and consent, addressed to their tutors, were given to the adolescent or
131
by checking another box stating "read and approve questionnaire by parents/legal guardians".
132
Concerning young adults, written consents were read carefully or obtained by checking the box stating
133
"read and approve questionnaire" In accordance with the ethics committee document, the written
134
consent was requested from adults or parents or guardians if the participant was minor (less than 18 4
ACCEPTED MANUSCRIPT 135
years) for signature. The survey was voluntary, anonymous, confidential and only for research
136
purposes to protect privacy and ensure data integrity. Ethics Committee approved the consent on
137
January 1st, 2013 and labeled the survey as a non-profit and non-sponsored study.
138
2.2.5. Statistical analysis The relation between HPV knowledge, acceptability of the HPV vaccine and the possible associated
140
factors were evaluated. Data were entered into a database using SPSS 20.0 for Windows (SPSS Inc,
141
Chicago, USA). Odds ratios (ORs), p value and 95% confidence intervals (CI) were obtained using
142
logistic regression models. A Stepwise multiple logistic regression was conducted to examine the
143
association of several factors controlling potential confounders. All variables for which a p value of ˂
144
0.05 were obtained in the univariate analysis were included in the multivariate logistic model.
145
3. Results
146
A total of 1308 subjects randomly invited from schools, universities and work to participate in the
147
study. Of the 246 (18.8%) subjects refused clearly, 158 (64.2%) were young adults.
148
acceptors having completed successfully the questionnaires, 18 were discarded because they were
149
married. Therefore, a total of 1044 participants (688 adolescents and 356 young adults) were included
150
in the final analysis (figure 1).The majority of the participants were female (84.2%). Two methods
151
were used to realize this survey; face to face and online questionnaire. The online questionnaire was an
152
alternative when the interviewed was busy at the moment of the interview. No different signification
153
was registered by using method of interview as an origin of variation (p>0.1).
154
Demographic characteristics, HPV knowledge and HPV vaccine acceptance among Moroccan youth
155
(adolescents and young adults) are shown in Table 2. Concerning the adolescent participants the mean
156
age was 16 years (range13-17 years). The majority were female (90.6%), had a secondary school level
157
of education (78.8%) and studied in public schools (95.6%). Most of them were not aware of HPV
158
(86.5%). The knowledge of CxCa origin was low (12.8%). Concerning the HPV vaccine, the majority
159
of interviewed refused to be vaccinated (83.1%). The young adults had an age mean of 25 (range, 18-
160
30). Most were female (71.9%), studied in public school (74.2%). About half of this group attended
161
university (52.8%). The majority of young adults interviewed were unaware of CxCa origin (71.3%)
162
and Pap tests (79.2%), 66.3% never heard of HPV. About 47% were willing to be vaccinated.
163
Regarding only participants having reported knowledge of HPV, 62.3% of adolescents and 45% of the
164
young adults had confirmed their knowledge that HPV infect both males and females. Two thirds of
165
youth (adolescents and young adults) confirmed their prior knowledge about the existence of
166
prophylactic vaccine. Finally only 1.6% of young adults versus 15.1% of adolescents said that their
167
parents recommended vaccinations against HPV.
Among 1062
AC C
EP
TE D
M AN U
SC
RI PT
139
5
ACCEPTED MANUSCRIPT 168
Table 3 shows percentage of positives answers about HPV knowledge and vaccine acceptance among
169
all participants. Univariate and multivariate logistic regression analysis were used among all studied
170
population (adolescents and young adults) to explore different demographic and cultural factors that
171
can be associated with HPV knowledge and with HPV vaccine acceptance ( Tables 4 and 5).
172
3.1. HPV knowledge In order to examine the knowledge about CxCa and HPV vaccine, a questionnaire was used in this
174
study. The univariate logistic regression analysis showed that several factors including gender, age,
175
educational level and knowledge of Pap test were significantly associated with HPV knowledge rates
176
(p
S1083-3188(15)00374-5
DOI:
10.1016/j.jpag.2015.11.002
Reference:
PEDADO 1923
To appear in:
Journal of Pediatric and Adolescent Gynecology
Received Date: 24 June 2015 Accepted Date: 12 November 2015
Please cite this article as: Zouheir Y, Daouam S, Hamdi S, Alaoui A, Fechtali T, Knowledge of Human Papillomavirus and Acceptability to Vaccinate in adolescents and young adults of Moroccan population, Journal of Pediatric and Adolescent Gynecology (2015), doi: 10.1016/j.jpag.2015.11.002. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT 1
Knowledge of Human Papillomavirus and Acceptability to Vaccinate in adolescents and young
2
adults of Moroccan population.
3
Yassine Zouheir 1, Samira Daouam 2, Salsabil Hamdi 1, Abdelaaziz Alaoui 3, Taoufiq Fechtali 1
4
1
5
Technics, Mohammedia, Hassan II University, Morocco. 2 Independent researcher, Casablanca,
6
Morocco; 3 Laboratory of Biotechnology, Valorisation and Protection of AgroResources, Faculty of
7
Science and Technology, Cadi Ayyad University, Marrakech.
8
The corresponding author: yassine zouheir, E-mail address: [email protected].
9
Abstract
SC
RI PT
Laboratory of Neurosciences, Integrated diseases and natural Substances, Faculty of sciences and
The human papillomavirus (HPV) infection is necessary cause of 99.7% of cervical cancer. Vaccines
11
can prevent up to 70% of the cervical cancer caused by HPV 16 and 18. The present study was
12
designed to define the knowledge of HPV and HPV vaccine acceptability among Moroccan youth. A
13
nationwide anonymous questionnaire with a sample of 688 adolescents (12-17 years) and 356 young
14
adults (18-30 years) was organized, that asked about HPV, origin of cervical cancer, Pap test and
15
acceptability of HPV vaccine. Data analyzed by using univariate and multivariate logistic regression
16
method. Overall, a low frequency (20%) of HPV knowledge was observed among studied population.
17
A multivariate model analysis showed that age, educational level and heard of Pap test remained
18
significantly associated factors with HPV knowledge. Additionally, only (27%) of participants were
19
willing to accept HPV vaccination. Highest acceptability was observed among young adults compared
20
to adolescents (46.6% vs 16.9%). Sixty two percent of males accepted the HPV vaccine compared to
21
only 20.4% of females. Educational level, type of school and knowledge of Pap test were associated
22
factors to HPV vaccine acceptability by multivariate model analysis. The present study showed a low
23
level of HPV knowledge and HPV vaccine acceptability among Moroccan youth. Promoting activities
24
and sensitization are required to maximize public awareness in the future. This objective can be
25
achieved by using media, active efforts by healthcare providers, and introducing of the sexual
26
education in schools program.
27
1. Introduction
28
Cervical cancer (CxCa) rates third as the most common cause of cancer among women worldwide.
29
With an annual incidence of more than 527,000 new cases (Age-standardized incidence rate (ASR): 14
30
per 100,000) and an annual mortality rate of 265,653 (ASR: 6.8) 1. Human papillomavirus (HPV) is
31
estimated to play an etiologic role in 99.7% of CxCa worldwide. Approximately 5.2% of all cancers
32
worldwide are attributed to HPV infection 2, 3. More than 70% of these cancers are caused by HPV 16
33
and HPV 18 genotypes 4.
AC C
EP
TE D
M AN U
10
1
ACCEPTED MANUSCRIPT In contrast to other developing countries in the world, the region of North Africa (NA) shows a
35
general low incidence of CxCa (ASR: 6.6). The availability and quality of the data are very different
36
from one country to another. Available data indicated that in Algeria, CxCa incidence ranks second
37
after breast cancer and third after breast and colorectal cancer in Tunisia, no data from Libya were
38
obtained. However, in Egypt, CxCa incidence/mortality data have been most extrapolated from limited
39
registries and could give a false impression that CxCa is not a major health issue 1, 3.
40
In Morocco, CxCa is considered as a major public health problem and it is the second most common
41
cancer among women after breast cancer with 2258 new cases and 1076 deaths each year
42
approximately 1. The incidence of CxCa could be much higher than reported, because published data
43
are limited to number of cases registered in some oncology centers in the absence of a national cancer
44
registry 5. The initiation of a National Cancer Control Plan, have started in 2010 to implement
45
organized screening programs using for CxCa detection 6. Two published studies focused on two
46
different regions of Morocco found a high HPV prevalence in women with normal cytology. The first
47
one was conducted in Ibn Sina Hospital, Rabat and showed a HPV prevalence of 15.8% in 2010.The
48
second study carried out at University Hospital of Fes in 2012, the HPV prevalence was 42.5%
49
None of the countries of this region has presently a National Organized CxCa Screening program;
50
Morocco and Tunisia are in the process to create such organization which can explain the highest HPV
51
prevalence in Morocco.
52
Two prophylactic HPV vaccines, Gardasil® (Merck&Co.,White house Station, NJ, USA) and
53
Cervarix® (GlaxoSmithKline Biologicals, Rixensart, Belgium) were approved in the United States
54
and Europe, respectively, and have been introduced in more than 100 countries worldwide to offer
55
protection against HPV types 16 and 18, which are responsible for the majority of CxCa [1]. The HPV
56
vaccine was licensed in Morocco since 2008 to reduce the incidence of HPV. The HPV vaccine cost
57
about $147 US (price of three-dose) constitutes approximately half a month’s income for 40% of
58
Moroccan families. In the absence of any state-funded vaccination program, it is beyond the means of
59
many people 9. The Moroccan national immunization program provides the vaccines against six
60
vaccine preventable diseases, including tuberculosis, diphtheria, pertussis, tetanus, polio and measles.
61
Adding HPV vaccine to the current national immunization program still a future perspective 10. The
62
efforts provided by the Lalla Salma Association led to the introduction of the HPV vaccine which
63
enabled the Expanded Program on Immunization (EPI) to immunize girls beginning at the age of 11.
64
This foundation was founded and headed by Princess Lalla Salma in 2005, dedicated to cancer
65
Prevention and treatment. The foundation has done Epidemiological research on HPV and is
66
supporting development of a large cervical cancer screening program. Various plans are being
67
introduced to prevent and control HPV infections which is a key advocate for HPV immunization 11.
68
The Centers for Disease Control and Prevention (CDC) reported that the HPV vaccination is
7, 8
.
AC C
EP
TE D
M AN U
SC
RI PT
34
2
ACCEPTED MANUSCRIPT 69
recommended for girls aged 13 through 26 and for boys aged 13 through 21. Ideally before beginning
70
sexual activity 12. Concerning the safety of the HPV vaccine, many studies including tens of thousands
71
of people worldwide showed no serious side effects, and confirmed the vaccine's efficiency. CDC and
72
the Food and Drug Administration (FDA) continue to control vaccine safety
73
the HPV vaccine by parents was recently studied in Morocco (2014). Responses showed very low
74
knowledge of both HPV infection (4.7%) rates and the HPV vaccine (14.3%). The acceptance of the
75
vaccine was low among mothers (32%) and fathers (45%), and none of the participants had vaccinated
76
their daughter(s) against HPV 16. The level of HPV knowledge and of the HPV vaccine acceptance
77
were different worldwide, some countries showed a low level, other exhibited a high one 17-20. To date,
78
there is an absence of data concerning the overall awareness of HPV and the acceptance of the HPV
79
vaccine among adolescents and young adults aged 12-30 in Morocco. Despite the high prevalence of
80
HPV infection among Moroccan women and the availability of a prophylactic HPV vaccine, we
81
expect a low level of HPV awareness and vaccine acceptability among adolescents and young adults
82
due to socio-religious, cultural barriers and non-introduction of the vaccine in EPI. So, the present
83
study was designed to outline the HPV knowledge level, the acceptance of HPV vaccine and their
84
factors associated among adolescents and young adults in Morocco.
85
2. Materials and methods
86
2.1. The study setting:
. The acceptance of
M AN U
SC
RI PT
12-15
The study was conducted from January 2014 to June 2014 at seven different regions across Morocco.
88
The studied regions were selected randomly. The capital of each region was included in the study for
89
the reason of its developed economy and high level of its population (Table1).
91
2.2. Study design
2.2.1. Study participants
EP
90
TE D
87
In the absence of any data about the HPV knowledge and acceptability of vaccine among Moroccan
93
youth, we targeted age groups for which vaccination is supposed to have been. Among 1290 subjects
94
aged between 12 and 30 selected randomly to participate in this study, 1044 subjects (688 adolescents
95
and 356 young adults) were accepted to participating and 246 were clearly refused (Figure 1). The
96
adolescents and young adults groups were randomly selected from schools and work or universities,
97
respectively. The variability of this population aimed to have a representative sample of different
98
economic, cultural and ethnic categories within the Moroccan society. Only unmarried participants
99
were retained in the final analysis, respecting the average age of marriage (29.5 years) indicated by the
100 101
AC C
92
high commission plan in 2004 in the urban area 21. 2.2.2. Study instruments 3
ACCEPTED MANUSCRIPT Two methods were adopted to collect data in this study: first one was the face to face interviews, the
103
second involved completing an electronic version of the questionnaire and forwarding it to the
104
corresponding author. The electronic form was considered as an alternative method when the
105
participants were not available or have a timid character (30 participants: 21 young adults and 9
106
adolescents). Participants were interviewed with a set of standard questionnaires about their socio-
107
demographic and cultural data (age, gender, educational level, private or public school). The
108
knowledge of HPV and HPV vaccine was assessed by using the questions: ‘have you ever heard about
109
HPV?’, ‘do you know the origin of cervical cancer?’, ‘do you know that HPV can infect both males
110
and females?’, ‘have you ever heard of a Pap test?’, ‘are you aware that a HPV prophylactic vaccine
111
exists?’. In addition, the acceptability of an HPV vaccine was studied by the following questions:
112
‘would you be willing to be vaccinated against HPV?’, ‘have your parents ever recommended the
113
vaccination against HPV?. The questionnaire was divided in three parts: (1) socio-demographic
114
characteristics of the participants, (2) knowledge of CxCa and HPV infection, and (3) acceptance of
115
HPV vaccination.
SC
2.2.3. Data Collection
M AN U
116
RI PT
102
117
The questionnaire was designed by researchers. Questions were based on a previously published
118
questionnaire in the literature
119
the interviewee’s preference, and took place at school, university or work again as chosen by the
120
participant.
121
To evaluate the possibility and acceptability of this study in a conservative society, and verify clarity,
122
correct wording the questions, pilot tests were performed for the baseline and follow-up surveys (n =
123
10, n = 10, respectively tow times). After these pre- tests some questions were eliminated to adapt the
124
study to our society (conservative Society and Islam religion too forbids sex before marriage).
EP
TE D
. The interviews were conducted in French or Arabic, according to
2.2.4. Ethical considerations
AC C
125
16, 22
126
All procedures performed in this study were in accordance with the ethical standards of the national
127
research committee and with the 1964 Helsinki declaration and its later amendments or comparable
128
ethical standards. The informed consent form was bound together with the questionnaire when it was
129
handed out to them. After selecting Adolescents group from class lists in each school, invitation
130
letters for the baseline interview and consent, addressed to their tutors, were given to the adolescent or
131
by checking another box stating "read and approve questionnaire by parents/legal guardians".
132
Concerning young adults, written consents were read carefully or obtained by checking the box stating
133
"read and approve questionnaire" In accordance with the ethics committee document, the written
134
consent was requested from adults or parents or guardians if the participant was minor (less than 18 4
ACCEPTED MANUSCRIPT 135
years) for signature. The survey was voluntary, anonymous, confidential and only for research
136
purposes to protect privacy and ensure data integrity. Ethics Committee approved the consent on
137
January 1st, 2013 and labeled the survey as a non-profit and non-sponsored study.
138
2.2.5. Statistical analysis The relation between HPV knowledge, acceptability of the HPV vaccine and the possible associated
140
factors were evaluated. Data were entered into a database using SPSS 20.0 for Windows (SPSS Inc,
141
Chicago, USA). Odds ratios (ORs), p value and 95% confidence intervals (CI) were obtained using
142
logistic regression models. A Stepwise multiple logistic regression was conducted to examine the
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association of several factors controlling potential confounders. All variables for which a p value of ˂
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0.05 were obtained in the univariate analysis were included in the multivariate logistic model.
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3. Results
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A total of 1308 subjects randomly invited from schools, universities and work to participate in the
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study. Of the 246 (18.8%) subjects refused clearly, 158 (64.2%) were young adults.
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acceptors having completed successfully the questionnaires, 18 were discarded because they were
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married. Therefore, a total of 1044 participants (688 adolescents and 356 young adults) were included
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in the final analysis (figure 1).The majority of the participants were female (84.2%). Two methods
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were used to realize this survey; face to face and online questionnaire. The online questionnaire was an
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alternative when the interviewed was busy at the moment of the interview. No different signification
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was registered by using method of interview as an origin of variation (p>0.1).
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Demographic characteristics, HPV knowledge and HPV vaccine acceptance among Moroccan youth
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(adolescents and young adults) are shown in Table 2. Concerning the adolescent participants the mean
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age was 16 years (range13-17 years). The majority were female (90.6%), had a secondary school level
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of education (78.8%) and studied in public schools (95.6%). Most of them were not aware of HPV
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(86.5%). The knowledge of CxCa origin was low (12.8%). Concerning the HPV vaccine, the majority
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of interviewed refused to be vaccinated (83.1%). The young adults had an age mean of 25 (range, 18-
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30). Most were female (71.9%), studied in public school (74.2%). About half of this group attended
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university (52.8%). The majority of young adults interviewed were unaware of CxCa origin (71.3%)
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and Pap tests (79.2%), 66.3% never heard of HPV. About 47% were willing to be vaccinated.
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Regarding only participants having reported knowledge of HPV, 62.3% of adolescents and 45% of the
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young adults had confirmed their knowledge that HPV infect both males and females. Two thirds of
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youth (adolescents and young adults) confirmed their prior knowledge about the existence of
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prophylactic vaccine. Finally only 1.6% of young adults versus 15.1% of adolescents said that their
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parents recommended vaccinations against HPV.
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Table 3 shows percentage of positives answers about HPV knowledge and vaccine acceptance among
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all participants. Univariate and multivariate logistic regression analysis were used among all studied
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population (adolescents and young adults) to explore different demographic and cultural factors that
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can be associated with HPV knowledge and with HPV vaccine acceptance ( Tables 4 and 5).
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3.1. HPV knowledge In order to examine the knowledge about CxCa and HPV vaccine, a questionnaire was used in this
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study. The univariate logistic regression analysis showed that several factors including gender, age,
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educational level and knowledge of Pap test were significantly associated with HPV knowledge rates
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(p
