School-based intervention for the prevention of HPV among adolescents: a cluster randomised controlled study

Maria Grandahl, Andreas Rosenblad, Christina Stenhammar, Tanja Tydén, Ragnar Westerling, Margareta Larsson, Marie Oscarsson, Bengt Andrae, Tina Dalianis, Tryggve Nevéus, Maria Grandahl, Andreas Rosenblad, Christina Stenhammar, Tanja Tydén, Ragnar Westerling, Margareta Larsson, Marie Oscarsson, Bengt Andrae, Tina Dalianis, Tryggve Nevéus

Abstract

Objective: To improve primary prevention of human papillomavirus (HPV) infection by promoting vaccination and increased condom use among upper secondary school students.

Design: Cluster randomised controlled trial.

Setting: 18 upper secondary schools in Sweden.

Participants: Schools were first randomised to the intervention or the control group, after which individual classes were randomised so as to be included or not. Of the 832 students aged 16 years invited to participate during the regular individual health interview with the school nurse, 751 (90.2%) agreed to participate and 741 (89.1%) students completed the study.

Interventions: The intervention was based on the Health Belief Model (HBM). According to HBM, a person's health behaviour can be explained by individual beliefs regarding health actions. School nurses delivered 30 min face-to-face structured information about HPV, including cancer risks and HPV prevention, by propagating condom use and HPV vaccination. Students in the intervention and the control groups completed questionnaires at baseline and after 3 months.

Main outcome measures: Intention to use condom with a new partner and beliefs about primary prevention of HPV, and also specifically vaccination status and increased condom use.

Results: All statistical analyses were performed at the individual level. The intervention had a significant effect on the intention to use condom (p=0.004). There was also a significant effect on HBM total score (p=0.003), with a 2.559 points higher score for the intervention group compared to the controls. The influence on the HBM parameters susceptibility and severity was also significant (p<0.001 for both variables). The intervention also influenced behaviour: girls in the intervention group chose to have themselves vaccinated to a significantly higher degree than the controls (p=0.02). No harms were reported.

Conclusions: The school-based intervention had favourable effects on the beliefs about primary prevention of HPV, and increased the HPV vaccination rates in a diverse population of adolescents.

Trial registration number: NCT02280967; Results.

Keywords: HPV; adolescents; prevention; randomised control trial; school-based.

Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Figures

Figure 1
Figure 1
Flow of schools and students through trial.

References

    1. Forman D, de Martel C, Lacey CJ et al. . Global burden of human papillomavirus and related diseases. Vaccine 2012;30(Suppl 5):F12–23. 10.1016/j.vaccine.2012.07.055
    1. Jemal A, Bray F, Center MM et al. . Global cancer statistics. CA Cancer J Clin 2011;61:69–90. 10.3322/caac.20107
    1. Paavonen J, Jenkins D, Bosch FX et al. . Efficacy of a prophylactic adjuvanted bivalent L1 virus-like-particle vaccine against infection with human papillomavirus types 16 and 18 in young women: an interim analysis of a phase III double-blind, randomised controlled trial. Lancet 2007;369:2161–70. 10.1016/S0140-6736(07)60946-5
    1. Lu B, Kumar A, Castellsagué X et al. . Efficacy and safety of prophylactic vaccines against cervical HPV infection and diseases among women: a systematic review & meta-analysis. BMC Infect Dis 2011;11:13 10.1186/1471-2334-11-13
    1. Leval A, Herweijer E, Ploner A et al. . Quadrivalent human papillomavirus vaccine effectiveness: a Swedish national cohort study. J Natl Cancer Inst 2013;105:469–74. 10.1093/jnci/djt032
    1. Nielson CM, Harris RB, Nyitray A et al. . Consistent condom use is associated with lower prevalence of human papillomavirus infection in men. J Infect Dis 2010;15:445–51. 10.1086/653708
    1. Winer RL, Hughes JP, Feng Q et al. . Condom use and the risk of genital human papillomavirus infection in young women. N Engl J Med 2006;354:2645–54. 10.1056/NEJMoa053284
    1. Markowitz LE, Tsu V, Deeks SL et al. . Human papillomavirus vaccine introduction—the first five years. Vaccine 2012;30(Suppl 5):F139–48. 10.1016/j.vaccine.2012.05.039
    1. Public Health Agency of Sweden. The childhood immunization program in Sweden 2013. Stockholm, 2014:76 (accessed 5 Aug 2015).
    1. Stenhammar C, Ehrsson YT, Åkerud H et al. . Sexual and contraceptive behavior among female university students in Sweden—repeated surveys over a 25-year period. Acta Obstet Gynecol Scand 2015;94:253–9. 10.1111/aogs.12565
    1. Herlitz CA, Forsberg M. Sexual behaviour and risk assessment in different age cohorts in the general population of Sweden (1989–2007). Scand J Public Health 2010;38:32–9. 10.1177/1403494809355072
    1. Johnson AM, Mercer CH, Beddows S et al. . Epidemiology of, and behavioural risk factors for, sexually transmitted human papillomavirus infection in men and women in Britain. Sex Transm Infect 2012;8:212–17. 10.1136/sextrans-2011-050306
    1. Ramqvist T, Dalianis T. An epidemic of oropharyngeal squamous cell carcinoma (OSCC) due to human papillomavirus (HPV) infection and aspects of treatment and prevention. Anticancer Research 2011;31:1515–19.
    1. Du J, Nordfors C, Ahrlund-Richter A et al. . Prevalence of oral human papillomavirus infection among youth, Sweden. Emerg Infect Dis 2012;18:1468–71. 10.3201/eid1809.111731
    1. Grandahl M, Tydén T, Rosenblad A et al. . School nurses’ attitudes and experiences regarding the human papillomavirus vaccination programme in Sweden: a population-based survey. BMC Public Health 2014;14:540 10.1186/1471-2458-14-540
    1. Grandahl M, Oscarsson M, Stenhammar C et al. . Not the right time: why parents refuse to let their daughters have the human papillomavirus vaccination. Acta Paediatr 2014;103:436–41. 10.1111/apa.12545
    1. Gottvall M, Grandahl M, Höglund AT et al. . Trust versus concerns-how parents reason when they accept HPV vaccination for their young daughter. Ups J Med Sci 2013;118:263–70. 10.3109/03009734.2013.809039
    1. Mattebo M, Grün N, Rosenblad A et al. . Sexual experiences in relation to HPV vaccination status in female high school students in Sweden. Eur J Contracept Reprod Health Care 2014;19:86–92. 10.3109/13625187.2013.878021
    1. Gottvall M, Tydén T, Höglund AT et al. . Knowledge of human papillomavirus among high school students can be increased by an educational intervention. Int J STD AIDS 2010;21:558–62. 10.1258/ijsa.2010.010063
    1. Marek E, Dergez T, Rebek-Nagy G et al. . Adolescents’ awareness of HPV infections and attitudes towards HPV vaccination 3 years following the introduction of the HPV vaccine in Hungary. Vaccine 2011;29:8591–8. 10.1016/j.vaccine.2011.09.018
    1. DiClemente RJ, Wingood GM, Sales JM et al. . Efficacy of a telephone-delivered sexually transmitted infection/human immunodeficiency virus prevention maintenance intervention for adolescents: a randomized clinical trial. JAMA Pediatr 2014;168:938–46. 10.1001/jamapediatrics.2014.1436
    1. Coyle KK, Glassman JR, Franks HM et al. . Interventions to reduce sexual risk behaviors among youth in alternative schools: a randomized controlled trial. J Adolesc Health 2013;53:68–78. 10.1016/j.jadohealth.2012.12.012
    1. Wingood GM, Diclemente RJ, Robinson-Simpson L et al. . Efficacy of an HIV intervention in reducing high-risk human papillomavirus, nonviral sexually transmitted infections, and concurrency among African American women: a randomized-controlled trial. J Acquir Immune Defic Syndr 2013;63(Suppl 1):S36–43. 10.1097/QAI.0b013e3182920031
    1. Kwan TT, Tam KF, Lee PW et al. . The effect of school-based cervical cancer education on perceptions towards human papillomavirus vaccination among Hong Kong Chinese adolescent girls. Patient Educ Couns 2011;84:118–22. 10.1016/j.pec.2010.06.018
    1. Rand CM, Brill H, Albertin C et al. . Effectiveness of centralized text message reminders on human papillomavirus immunization coverage for publicly insured adolescents. J Adolesc Health 2015;56(5 Suppl):S17–20. 10.1016/j.jadohealth.2014.10.273
    1. Fu LY, Bonhomme LA, Cooper SC et al. . Educational interventions to increase HPV vaccination acceptance: a systematic review. Vaccine 2014;32:1901–20. 10.1016/j.vaccine.2014.01.091
    1. Gilkey MB, Dayton AM, Moss JL et al. . Increasing provision of adolescent vaccines in primary care: a randomized controlled trial. Pediatrics 2014;134:e346–53. 10.1542/peds.2013-4257
    1. Statistics Sweden Secondary Statistics Sweden 2013. (accessed 8 Aug 2015).
    1. Statue Book of Sweden Education Act 2010:800. [Svensk författningssamling Skollagen 2010:800]. Sweden: The Committee on Education [Utbildningsdepartementet] 2010.
    1. Juraskova I, Bari RA, O'Brien MT et al. . HPV vaccine promotion: does referring to both cervical cancer and genital warts affect intended and actual vaccination behavior? Womens Health Issues 2011;21:71–9. 10.1016/j.whi.2010.08.004
    1. Donadiki EM, Jiménez-García R, Hernández-Barrera V et al. . Health Belief Model applied to non-compliance with HPV vaccine among female university students. Public Health 2014;128: 268–73. 10.1016/j.puhe.2013.12.004
    1. Roye C, Perlmutter Silverman P, Krauss B. A brief, low-cost, theory-based intervention to promote dual method use by black and Latina female adolescents: a randomized clinical trial. Health Educ Behav 2007;34:608–21. 10.1177/1090198105284840
    1. Champion VL, Skinner Sugg C. The health belief model. In: Glantz K, Rimer BK, Viswanath K, eds. Health behavior and health education: theory, research and practice. 4th edn San Fransisco, CA, USA: Jossey-Bass, 2008:45–65.
    1. Lundberg M, Färdig M. Gymnasieelevers kunskap om och inställning till HPV och HPV-vaccin. Uppsala University, 2014. (accessed 3 Oct 2015).
    1. National health questionnaire for adolescents [Liv och hälsa ung] Secondary National health questionnaire for adolescents [Liv och hälsa ung] 2013. (accessed 15 Feb 2015).
    1. CODEX rules and guidelines for research. Secondary CODEX rules and guidelines for research 2015. (accessed 4 Oct 2015).
    1. Larsson M, Eurenius K, Westerling R et al. . Evaluation of a sexual education intervention among Swedish high school students. Scand J Public Health 2006;34:124–31. 10.1080/14034940510032266
    1. Lu PJ, Rodriguez-Lainz A, O'Halloran A et al. . Adult vaccination disparities among foreign-born populations in the U.S., 2012. Am J Prev Med 2014;47:722–33. 10.1016/j.amepre.2014.08.009
    1. Azerkan F, Zendehdel K, Tillgren P et al. . Risk of cervical cancer among immigrants by age at immigration and follow-up time in Sweden, from 1968 to 2004. Int J Cancer 2008;123:2664–70. 10.1002/ijc.23843
    1. Azerkan F, Sparén P, Sandin S et al. . Cervical screening participation and risk among Swedish-born and immigrant women in Sweden. Int J Cancer 2012;130:937–47. 10.1002/ijc.26084
    1. Ekstrand M, Tydén T, Larsson M. Exposing oneself and one's partner to sexual risk-taking as perceived by young Swedish men who requested a Chlamydia test. Eur J Contracept Reprod Health Care 2011;16:100–7. 10.3109/13625187.2010.549253
    1. Shepherd JP, Frampton GK, Harris P. Interventions for encouraging sexual behaviours intended to prevent cervical cancer. Cochrane Database Syst Rev 2011;(4):CD001035 10.1002/14651858.CD001035.pub2

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