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A community-based intervention in middle schools to improve HPV vaccination and cervical cancer screening in Japan

A community-based intervention in middle schools to improve HPV vaccination and cervical cancer... Aim: Japan has low rates of cervical cancer screening and Human papilloma virus (HPV) vaccination. This research examines the effectiveness of a family medicine resident-led, intervention in increasing knowledge about HPV and cervical cancer in middle school-girls and increasing knowledge and intention to have cervical cancer screening in their mothers. th Methods: We utilized a pre-test/post-test intervention design in three rural middle schools with 7 grade middle school-girls and their mothers. A school-based activity educated girls about HPV and cervical cancer. A home-based activity utilized a homework assignment for girls and their mothers. Pre/post intervention surveys were completed by the girls and their mothers. Major outcomes included changes in knowledge among girls and mothers and barriers to be screened for cervical cancer among mothers. Results: Sixty-five students and sixty-three mothers completed the study. Two out five mothers were not in compliance with current screening recommendations. Identified barriers included: embarrassment (79%), poor access (56%), fear of having cancer (52%), and cervical cancer screening being an unknown procedure (46%). Forty-four percent of mothers deemed their daughters to be at risk for cervical cancer. Trusted sources of information included: doctors (97%), newspapers/television (89%), government (79%), the Internet (78%), and friends (62%). Student knowledge scores (7-point scale) improved significantly from pre- to post-intervention (4.8 vs. 5.9, p < 0.001). Knowledge scores (14-point scale) among mothers also significantly improved (11.7 vs. 12.0, p = 0.024). Conclusions: These data suggest a community-based intervention on a sensitive topic by family medicine residents can be implemented in middle schools, can improve school-girls’ knowledge about HPV and cervical cancer, and can reach their mothers. Additional research could examine whether those intending to be screened receive screening and how to reach women who still resist screening. Keywords: Early detection of cancer, Japan, Papillomavirus vaccines, Vaccination, Intervention Summary of implications of the research/article vaccination and cervical cancer screening. About two of for practicing GP’s five mothers in this rural area were not in compliance This research illustrates that a community-based interven- with cervical cancer screening. Reported barriers to tion featuring a lecture by family physicians to middle screening included: embarrassment, poor access, fear of school-girls, followed by a homework assignment for the having cancer, and cervical cancer screening being an un- girls and mothers, can increase knowledge about HPV known procedure. While these girls and mothers under- stand that HPV infection can cause cancer, confusion persisted about whether all forms of HPV infection are * Correspondence: tomoko_itou@hotmail.com; remi.japan@gmail.com linked to cervical cancer. The intervention did not in- Shiga Center for Family Medicine, 1825 Yuge, Ryuo, Gamo District, Shiga crease substantively the number of mothers intending to Prefecture 520-2501, Japan Shizuoka Family Medicine Program, Shizuoka, Japan be screened; this is likely due to high rates of intention to Full list of author information is available at the end of the article © 2014 Ito et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Ito et al. Asia Pacific Family Medicine 2014, 13:13 Page 2 of 8 http://www.apfmj.com/content/13/1/13 be screened at baseline. As virtually all mothers consider million HPV inoculations included: anaphylaxis - one case, physicians a trustworthy information source, physicians Guillan-Barre syndrome - 0.6 cases, acute disseminated en- should actively encourage daughter and mother participa- cephalomyelitis (ADEM) - 0.4 cases, though the relationship tion in these preventive services. between these symptoms and vaccination were not proven. In all, 20 cases per 1 million were rated as serious cases of Introduction pains or body convulsions, pains in joints or difficulty in Cervical cancer is the second most common cancer walking[6].Thisislessthanthe 26.0serious casesper among women between the ages of 20–49 in Japan [1]. million inoculations of Japanese encephalitis vaccine [5]. Japan had a national cervical cancer screening program With regard to the burden of cervical cancer in Japan, in a from 1982 to 1998 targeting women 40 years of age and ten-year period, about 16,000-28,000 women per year are di- older; however, this national program ended when the agnosed with cervical cancer and about 2,400-2,700 of them responsibility was transferred to local governments. The die as a result [7-9]. current cervical cancer screening recommendation in Educational efforts by health professionals have the po- Japan is to screen women 20 years of age and older every tential to enhance knowledge among adolescents and adult two years [2]. Since 2009, the Japanese government has women about cervical cancer, the purpose of screening, offered a free cervical cancer screening coupon to and the value of prevention through HPV vaccination women at the ages of 20, 25, 30, 35, and 40 [3]. Despite [3,10]. Given their role in “womb-to-tomb” care, family these recommendations and incentives, Japan has the physicians are well placed in the community for playing an lowest rate of cervical cancer screening among devel- influential role in promoting HPV vaccination and cervical oped countries [4]. cancer screening. The purpose of this research was to as- Despite an initial start with a compulsory vaccination pro- sess the feasibility of a family medicine resident-led, school- gram, Japan differs from other developed countries in the based educational intervention to increase knowledge of adoption of HPV vaccination. Human Papilloma Virus cervical cancer and the role of HPV vaccinations in middle (HPV) vaccination has been shown to be effective for pre- school-girls while indirectly increasing knowledge and cer- venting cervical cancer and began in 2009 in Japan. A com- vical cancer screening intentions in their mothers. pulsory program to have HPV vaccinations began in Japan in April of 2013; however, case reports emerged suggesting Materials and methods severe side effects of HPV vaccine. Hence, the Japanese gov- Design, setting and participants ernment withdrew the compulsory program in June, 2013. We utilized a pre-test/post-test intervention design The Japan Times [5] reported a total of 8.29 million people (Figure 1). The study took place in three middle had received HPV vaccines through December 2012. Ac- schools in the rural town of Shizuoka Prefecture, cording to a Ministry of Health, Labour and Welfare Japan in April and May, 2013. Participants included th (MHLW) panel, 1,925 cases of side effects were reported first-year female middle school students (7 grade through the end of December 2012. In the MHLW report equivalent) from the three schools and their mothers. from July, 2014, the rate of very serious side effects per one All female students and their mothers were eligible Figure 1 Study design. Ito et al. Asia Pacific Family Medicine 2014, 13:13 Page 3 of 8 http://www.apfmj.com/content/13/1/13 for inclusion; there were no exclusion criteria. This sources of information, and appropriate times to educate project was approved by the Hamamatsu Medical daughters about cervical cancer screening. This instru- School Institutional Review Board. ment required mothers about 15 to 20 minutes to complete. Mothers also completed five demographics Intervention items on age, highest educational level, personal and The project involved a two-part intervention with both family experience with cervical cancer, and history of school-based and home-based components. The school- cervical cancer screening administered pre-intervention based component lasted approximately one hour, and only. Both student and mother instruments targeted a th was comprised of a 20-minute slide presentation by two 6 grade reading level. female family physicians (TI and RT) about HPV and cervical cancer, and a 9-item worksheet filled out by middle school-girls during the presentation. It was car- Data analysis ried out using an interactive-lecture format in a school Descriptive statistics were calculated for demographic var- classroom. The content was developed to address three iables filled out by the mothers at the baseline survey. The fundamental topics: 1) the high prevalence and incidence major outcomes included changes in student knowledge of cervical cancer among young women, 2) cervical can- of HPV and cervical cancer pre- and post-intervention, cer is preventable and 3) how to prevent cervical cancer. mothers’ knowledge, attitudes and beliefs, mothers’ inten- The school-based component was reviewed with teacher tions to obtain cervical cancer screening, and differences representatives of the three participating middle schools. between mothers compliant with cervical cancer screening Any content felt by the teachers to have sexual connota- recommendations and those not compliant. Sixty-three tions was not acceptable and removed. The school mothers completed both the pre- and post-intervention teachers agreed to the final content. The home-based survey (Table 1). Two mother-daughter pairs did not an- component centered on a required homework assign- swer any questions on the post questionnaire and were ment in which the girls reviewed the worksheet they had not included in the analyses. For some instruments, par- completed with their mothers. ticipants did not answer all questions. Such unanswered questions were treated as missing values and the results Data collection reported are based on valid responses, except as indicated Pre-/post-surveys about HPV and cervical cancer screen- below for the knowledge questions. ing were administered to assess knowledge of HPV and Knowledge scores for students were computed by cervical cancer among the middle school-girls. The inves- summing together the number of correct responses on tigators distributed the pre-intervention survey three days seven applicable knowledge questions asked at both pre- before the school-based exercise with the girls. The post- and post-intervention. In cases where students missed intervention survey was distributed after the school-based answering a question (one case at pre- and one post- exercise taken by the girls, and the post-intervention sur- intervention), missing responses were treated as ‘incor- veys were collected within the following seven days. rect’ responses. Two questionnaires filled out by fathers This survey was developed using questions from previ- were dropped from the analyses since the questions were ously published surveys [11-19] and included 9 true/false designed for women. The two girls whose fathers had questions that required 5–10 minutes to complete. A completed the parent survey were included in the ana- similar instrument that differed by having more ques- lysis of student scores. All 67 students had scores for the tions was administered to the mothers that assessed pre-survey and at post there were 65 valid scores (2 stu- knowledge, beliefs about HPV and cervical cancer, as dents did not complete any of the post questionnaire). well as future intentions to be screened for cervical can- Scores could range from 0 to 7 based on responses to cer. The instrument for mothers included 20 items. This the 7 knowledge questions. Average scores were com- survey involved true/false questions (including the same pared for the 65 students who completed both surveys questions asked of the daughters), as well as additional using a paired t-test. questions that were specific to the mothers or deemed Mothers’ knowledge scores were computed by sum- not appropriate for students by the school (ie., whether ming together the number of correct responses on 14 HPV is sexually transmitted, whether having the vaccine applicable knowledge questions asked at both pre- and precludes the need for screening, and whether cervical post-intervention. As with students, a missing response cancer screening should be done regularly). Additional by any of the mothers when other questions had been questions were posed to mothers using a four-point answered was considered incorrect. Knowledge scores Likert scale addressing prevention of cervical cancer, could range between 0 and 14. The item measuring their risks of cervical cancer for their daughters in the intention to be screened in the future, “Do you intend future, barriers to cervical cancer screening, trustworthy to be screened for cervical cancer?” originally had Ito et al. Asia Pacific Family Medicine 2014, 13:13 Page 4 of 8 http://www.apfmj.com/content/13/1/13 Table 1 Mother demographics N = 63 Compliant (n = 39) Non-compliant (n = 25) Overall N (%) Age, p-value = 0.803 <=30 1 (2.6) 0 (0.0) 1 (1.6) 31-35 3 (7.9) 4 (16.0) 7 (11.1) 36-40 10 (26.3) 7 (28.0) 17 (27.0) 41-45 19 (50.0) 10 (40.0) 29 (46.0) > = 46 5 (13.2) 4 (16.0) 9 (14.3) Education, p value = 0.332 Junior High School 2 (5.3) 0 (0.0) 2 (3.2) High School 13 (34.2) 14 (56.0) 27 (42.9) College/Special School 19 (50.0) 9 (36.0) 28 (44.4) University 4 (10.5) 2 (8.0) 6 (9.5) Cervical Cancer History [n = 58], p value = 1.00 Herself 1 (2.9) 0 (0.0) 1 (1.7) Family/Relatives 1 (2.9) 0 (0.0) 1 (1.7) Friends 2 (5.7) 2 (8.7) 4 (6.9) None/Don’t Know 31 (88.6) 21 (91.3) 52 (89.7) responses of “no,”“yes, in this year” and “yes, in 2–3 Daughters’ and mothers’ knowledge about HPV and years.” This was dichotomized into “no” or “yes.” cervical cancer Regarding two change-in-beliefs questions asking about Figure 2 provides a comparison of student and mother mothers’ trust of information from multiple sources and knowledge scores. Average knowledge scores for students appropriate timing of education about cervical cancer on a seven-point scale were significantly higher from before education, the categories (strongly disagree, disagree, to after the intervention (4.8 vs. 5.9, p-value < 0.001). Simi- agree and strongly agree) were collapsed into two categor- larly, average scores for mothers on a 14-point scale for the ies (agree vs. disagree). The responses to these questions 63 mothers who completed both surveys were significantly from mothers between pre- and post- were compared higher from before to after the intervention (11.7 vs. 12.0, using the McNemar test. p-value = 0.024). The relationship between change in score for both mother and daughter was investigated by categorizing Results the change for both groups as increasing, staying the Demographics same or decreasing. Cross-tabulation was used to exam- th Sixty-five female 7 grade students completed the study ine the relationship between corresponding mother and and were either 12 or 13 years of age. Most mothers were daughter score changes. A chi-square test was not sig- over the age of 40 (60%) and all but 2 had graduated from nificant (Fisher’s Exact p-value = 0.664), indicating that a high school. Regarding personal experience with cervical change in score for students from pre- to post- was in- cancer, only one of the mothers had a personal history of dependent of change in score for mothers, i.e., increase cervical cancer, while five had a relative or friend who had in students’ knowledge scores doesn’t correspond to an had cervical cancer. At baseline 19 mothers reported that increase in mothers’ knowledge scores. they had never been screened for cervical cancer, while an- As shown in Table 2, responses to specific knowledge other 6 indicated that they had not been screened in more questions improved for most items; however, unexpect- than 3 years. Thus, 25 (40%) mothers were not compliant edly, both student and mother understanding that all with screening recommendations at baseline. Regarding HPV infections do not lead to cervical cancer decreased. perception of their daughters’ vulnerability to getting Otherwise, for students, increase in knowledge scores cervical cancer in the future, 28 (44%) respondents agreed were seen on all other questions with greatest gains in or strongly agreed that their daughters were vulnerable to understanding that HPV causes cervical cancer (44% future cervical cancer. There was no relationship between improvement), cervical cancer is asymptomatic at an agreeing/disagreeing with this statement and maternal age, early stage (32% improvement), and cervical cancer is education, cervical cancer history or intention to be preventable (25% improvement). Mother knowledge screened pre-intervention. scores were high at baseline, and increases in knowledge Ito et al. Asia Pacific Family Medicine 2014, 13:13 Page 5 of 8 http://www.apfmj.com/content/13/1/13 Figure 2 Comparison of student and mother knowledge scores pre- and post- intervention*. *Since students and mothers answered a different number of knowledge questions, student scores could range from 0 to 7, while mother scores could range from 0 to 14. Comparison on the same scale was made by dividing the score by the maximum possible (7 for students and 14 for mothers). were modest, though a clinically notable difference was a Mothers’ beliefs about barriers to cervical cancer 14 percentage point gain for understanding that safe sexual screening practices can prevent cancer. When comparing knowledge Mothers also responded to questions about barriers to cer- scores among mothers compliant with cervical cancer vical cancer screening and prevention of cervical cancer. At screening recommendations and among mothers not com- the baseline assessment, many mothers identified barriers to pliant, there were no significant differences. cervical cancer screening including: embarrassment (79%), Table 2 Correct knowledge about HPV vaccine and cervical cancer responses of students and mothers Students, N = 65 Mothers, N = 63 Pre Post Pre Post Cervical cancer is caused by HPV infection? 46% 100% 86% 97% Cervical cancer is genetic? 51% 63% 71% 81% All HPV infections lead to cervical cancer? 75% 49% 89% 76% Cervical cancer is decreasing in recent years? 83% 92% 100% 98% Cervical cancer is preventable? 72% 97% 70% 78% Cervical cancer is asymptomatic usually in early stage? 65% 97% 98% 98% Early detection of cervical cancer might save one’s life? 85% 92% 95% 97% HPV is sexually transmitted? NA NA 91% 97% If vaccinated, you don’t need to be screened? NA NA 98% 97% Screening test should be done regularly? NA NA 92% 95% HPV vaccination can prevent cervical cancer NA NA 95% 95% Safe sex (steady partner, use of condoms) can prevent cervical cancer NA NA 75% 89% Pap test can prevent cervical cancer NA NA 94% 95% Healthy lifestyle (ie., regular exercise, disciplined lifestyle, healthy diet) can prevent cervical cancer NA NA 11% 11% NA = Not asked as deemed to be too sensitive and unacceptable by the local middle schools. Ito et al. Asia Pacific Family Medicine 2014, 13:13 Page 6 of 8 http://www.apfmj.com/content/13/1/13 poor access (56%), fear of having cancer (52%), and cer- with cervical cancer screening. Identified barriers to screen- vical cancer screening being an unknown procedure ing included: embarrassment, poor access, fear of having (46%). Among mothers who were in compliance and cancer, and cervical cancer screening being an unknown mothers out of compliance with cervical cancer screen- procedure. As previous screening predicts future intention ing recommendations, there were differences in their re- to be screened, the women with greatest need are those sponses on the importance of cervical cancer screening who are not currently compliant. Close to half of mothers being an unknown procedure, with 72% of non- (44%) feel that their daughters are at risk for cervical cancer compliant mothers agreeing and only 29% of compliant in the future. For their education, mothers identify as par- mothers agreeing (p-value < 0.001). ticularly trusted sources of information their doctors and media/newspapers. Mothers’ beliefs about trustworthy sources of information Student and mother knowledge scores improved sig- and timing of education about HPV and cervical cancer nificantly from baseline to post-intervention, indicating screening that in the short term this school-based intervention Mothers answered questions about sources of trusted infor- was effective for promoting knowledge about HPV vac- th mation and beliefs about when it is appropriate to educate cination and cervical cancer screening for 7 grade girls. women at baseline assessment. Regarding sources of The magnitude of improvement was much greater for trusted information about cervical cancer, the percent indi- the students than mothers, attributable to the high base- catingstrongagreement or agreement for five sources was: line knowledge scores. It was not possible to assess long- doctors (97%), newspapers/television (89%), government term knowledge retention, nor whether the intervention (79%), the Internet (78%), and friends (62%). Mothers also actually impacted the rate of HPV vaccinations among were asked about the appropriate timing of education about these middle school-girls, nor the rate of cervical cancer cervical cancer, and at baseline, the percent indicating screening of their mothers. strong agreement or agreement for four sources was: begin- Despite high knowledge scores at baseline, 40% of the ning of junior high (83%), end of junior high (79%), high mothers were not in compliance with cervical cancer school (65%) and college or later (52%). When compared screening. This suggests that there are other factors be- pre- and post- intervention using McNemar’s test, there sides knowledge that impact these women’s decision were no differences for either trusted source of information making about whether to receive cervical cancer screen- or beliefs, an indication that the intervention did not have ing. Previous research suggests factors that may prove to an effect on these factors. be barriers to cervical cancer screening. Fetters et al. found that 12 of 19 Japanese women receiving care in a Impact of intervention on intention to receive cervical U.S. clinic approved of the U.S. style of the pelvic exam- cancer screening among those not compliant with ination and they valued such measures as using a private screening guidelines room, covering the perineum with a sheet and explain- Twenty-five mothers (40%), including 19 who had reported ing the procedures being used [20]. This contrasts with no history of cervical cancer screening and six who reported the typical style of examination in Japan where a woman no screening in over 3 years, were not in compliance with receives pelvic examinations lying on an examination Japanese screening recommendations. In the subset of 23 table in a stall with a curtain placed at the waist for priv- mothers who answered both the pre- and post-intervention acy even though her pelvis is exposed openly to staff survey, five women who had not indicated an intention to [20]. In an opinion paper, Konno et al. mentioned that be screened at baseline, changed and indicated intention to in order to make public health measures of cervical can- be screened after the intervention. A McNemar test indi- cer effective, education, environment and enforcement cated that the intervention did not significantly promote are very important, but that the Japanese cervical cancer intention to receive cervical cancer screening on those out screening environment gives the patients no control and of compliance, though sample size is small so ability to make often no privacy [3]. In related research from Taiwan, inferences is limited. A chi-squared test indicated a signifi- Wu found barriers to breast cancer screening to include: cant relationship with those who had been screened in the 1) excuses (no time, forgot, cumbersome and lazy), 2) no past being more likely to intend on being screened again need for screening, 3) modesty, 4) discomfort, 5) logis- (100.0% vs. 65.2%, p < 0.001). tics, 6) lack of information/knowledge, and 7) fear of finding cancer [11]. In their report about barriers to Discussion HPV vaccination in Asia Oceania, Garland et al. raise These data provide information about the nature of know- the barrier of reluctance to discuss issues around sex ledge about HPV vaccination and cervical cancer risk in [11]. This barrier clearly applies in Japan where medical one rural community. These findings illustrate that two out students have no routine exposure to discussions on of five mothers in this rural area were not in compliance sexuality. Few family medicine training programs in Ito et al. Asia Pacific Family Medicine 2014, 13:13 Page 7 of 8 http://www.apfmj.com/content/13/1/13 Japan even offer women’s health training [21]. Few prac- Medicine program, and Ayaka Yajima of the University of Michigan for their assistance. ticing primary care physicians provide contraceptive or prenatal [22,23]. Reluctance to have screening may also Author details reflect a sense of vulnerability, or unpleasant, negative Shiga Center for Family Medicine, 1825 Yuge, Ryuo, Gamo District, Shiga Prefecture 520-2501, Japan. Shizuoka Family Medicine Program, Shizuoka, experiences, e.g., discomfort, poor explanations in the Japan. Department of Obstetrics, Gynecology and Family Medicine, past [3,20]. Future research should explore the potential Hamamatsu University, School of Medicine, Hamamatsu, Shizuoka, Japan. barriers to, and benefits of, women seeking care for Department of Family Medicine, University of Michigan, Ann Arbor, Michigan, USA. Department of Family Medicine and Community Health, women’s health issues with family physicians. Research Division, Rutgers Robert Wood Johnson Medical School, Piscataway, There are a number of limitations to this study. While New Jersey, USA. Mori Machi Family Medicine Clinic, 387-1 Kusagaya, Mori, the educational intervention content was appropriate for Shuchi District, Shizuoka Prefecture 437-0214, Japan. improving student knowledge, it may be insufficient for the Received: 5 August 2014 Accepted: 29 October 2014 educational needs of their mothers. While there was mean- ingful increase in the number of women who intended to be screened after the intervention, it is not clear whether References the intervention was actually linked to the mothers’ inten- 1. Matsuda A, Matsuda T, Shibata A, Katanoda K, Sobue T, Nishimoto H: Cancer incidence and incidence rates in Japan in 2007: a study of 21 tions to be screened. A number of mothers reported they population-based cancer registries for the monitoring of cancer had never been screened for cervical cancer. As obtaining a incidence in Japan (MCIJ) project. Jpn J Clin Oncol 2013, 43:328–336. Pap smear is routine practice with all pregnant women, it is 2. Hamashima C, Aoki D, Miyagi E, Saito E, Nakayama T, Sagawa M, Saito H, Sobue T: Japanese guideline for cervical cancer screening. Jpn J Clin likely that those reporting that they had never been Oncol 2010, 40:485–502. screened were unaware of that they had been screened 3. Konno R, Sagae S, Yoshikawa H, Basu PS, Hanley SJB, Tan JHJ, Shin H-R: when pregnant with their daughters-interpreting them as Cervical cancer working group report. Jpn J Clin Oncol 2010, 40:i44–i50. 4. OECD Publications: OECH health data 2011. Paris: Organization for Economic non-compliant is still a reasonable position. Finally, the Co-operation and Development (OECD); 2011. current survey was unable to discern reasons for why 5. HPV vaccine raises questions (Editorial): The Japan Times. 2013. June 14. women continue to resist cervical cancer screening despite 6. Ministry of Health, Labour and Welfare: HPV vaccination. 2013. http://www. mhlw.go.jp/bunya/kenkou/kekkaku-kansenshou28/pdf/tsuuchi_h26_07_ apparently having good knowledge about cervical cancer 16_1c.pdf. and HPV. Future research could explore such reasons with 7. Matsuda A, Matsuda T, Shibata A, Katanoda K, Sobue T, Nishimoto H: the aid of depth interviews of mothers and daughters from Cancer incidence and incidence rates in Japan in 2008: a study of 25 population-based cancer registries for the monitoring of cancer both the “changed-behavior group” and the “unchanged-be- incidence in Japan (MCIJ) project. Jpn J Clin Oncol 2014, 44:388–396. havior group.” 8. Center for Cancer Control and Information Services: Cancer mortality from A follow-up survey will be needed to determine if Vital Statistics in Japan (1958–2012). National Cancer Center; 2014. 9. Center for Cancer Control and Information Services: National estimates of intention to receive cervical cancer screening translates into cancer incidence based on cancer registries in Japan (1975–2010). Japan: care-seeking behavior. The current research suggests this National Cancer Center; 2013. relatively inexpensive, community-based intervention pro- 10. Garland SM, Cuzick J, Domingo EJ, Goldie SJ, Kim YT, Konno R, Parkin DM, Qiao YL, Sankaranarayanan R, Stern PL, Tay SK, Bosch FX: vides a novel strategy for reaching individuals in the com- Recommendations for cervical cancer prevention in Asia Pacific. munity who are not necessarily accessing the health care Vaccine. 2008, 26(Suppl 12):M89–98. system. If further research on actual behavior is positive, 11. Wu TY, Chung S, Yeh MC, Chang SC, Hsieh HF, Ha SJ: Understanding breast cancer screening practices in Taiwan: a country with universal such community-based interventions could be used as a health care. Asian Pac J Cancer Prev 2012, 13:4289–4294. tool for increasing HPV vaccination and cervical cancer 12. Gu C, Chan CW, He GP, Choi KC, Yang SB: Chinese women's motivation to screening throughout Japan. receive future screening: the role of social-demographic factors, know- ledge and risk perception of cervical cancer. Eur J Oncol Nurs 2013, 17:154–161. Competing interests 13. Luszczynska A, Goc G, Scholz U, Kowalska M, Knoll N: Enhancing intentions The authors declare that they have no competing interests. to attend cervical cancer screening with a stage-matched intervention. Br J Health Psychol. 2011, 16:33–46. Authors’ contributions 14. Laranjeira CA: Portuguese women's knowledge and health beliefs about TI and RT contributed to design development, implementation of the cervical cancer and its screening. Soc Work Public Health. 2013, 28:150–157. intervention, data analysis and presentation, and authoring of the paper. KN 15. Kahn JA, Ding L, Huang B, Zimet GD, Rosenthal SL, Frazier AL: Mothers' contributed to design development, advising about the intervention, intention for their daughters and themselves to receive the human interpretation of the data and final editing of the paper. MP and AS papillomavirus vaccine: a national study of nurses. Pediatrics. 2009, contributed to the data analytics, interpretation, presentation, and authoring 123:1439–1445. of the paper. BF and MF contributed to the design development, advising 16. Price RA: Knowledge and intention to participate in cervical cancer about the intervention, data analysis and presentation, and authoring of the screening after the human papillomavirus vaccine. Vaccine. 2011, paper. All authors reviewed and approved of the submitted manuscript. 29:4238–4243. 17. Wong LP: Knowledge and attitudes about HPV infection, HPV Acknowledgements vaccination, and cervical cancer among rural Southeast Asian women. We thank the students, parents and teachers of Morimachi town. We Int J Behav Med 2011, 18:105–111. appreciate the helpful advice of Drs. John W. Creswell, Paryono Paryono, and 18. Black LL, Zimet GD, Short MB, Sturm L, Rosenthal SL: Litrature review of Karl Rew. We also thank Kiyomi Ozawa of the Morimachi Educational human papillomavirus vaccine acceptability among women over Committee, Natsuko Morita and Sachiko Takeshita of the Shizuoka Family 26 years. Vaccine. 2009, 27:1668–1673. Ito et al. Asia Pacific Family Medicine 2014, 13:13 Page 8 of 8 http://www.apfmj.com/content/13/1/13 19. Marlow LA, Zimet GD, McCaffery KJ, Ostini R, Waller J: Knowledge of human papillomavirus (HPV) and HPV vaccination: an international comparison. Vaccine 2013, 31:763–769. 20. Fetters MD, Masuda Y, Sano K: Japanese women's perspectives on pelvic examinations in the United States. Looking behind a cultural curtain. J Reprod Med 2003, 48:194–200. 21. Fetters MD, Fujioka Y: なぜ、日本の家庭医学研修に婦人医療研修が含 まれるべきなのか? (Why women's health training is needed during family medicine residency training in Japan). Jpn J Fam Pract 2009, 15:44–51. 22. Kitamura K, Fetters MD, Ban N: Contraceptive care by family physicians and general practitioners in Japan: Attitudes and practices. Fam Med 2004, 36:279–283. 23. Kitamura K, Fetters MD, Ban N: Preconception care by family physicians and general practitioners in Japan. BMC Fam Pract 2005, 6:31. doi:10.1186/s12930-014-0013-0 Cite this article as: Ito et al.: A community-based intervention in middle schools to improve HPV vaccination and cervical cancer screening in Japan. Asia Pacific Family Medicine 2014 13:13. 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A community-based intervention in middle schools to improve HPV vaccination and cervical cancer screening in Japan

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Springer Journals
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Copyright © 2014 by Ito et al.; licensee BioMed Central Ltd.
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Medicine & Public Health; General Practice / Family Medicine; Primary Care Medicine
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1447-056X
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10.1186/s12930-014-0013-0
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25431533
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Abstract

Aim: Japan has low rates of cervical cancer screening and Human papilloma virus (HPV) vaccination. This research examines the effectiveness of a family medicine resident-led, intervention in increasing knowledge about HPV and cervical cancer in middle school-girls and increasing knowledge and intention to have cervical cancer screening in their mothers. th Methods: We utilized a pre-test/post-test intervention design in three rural middle schools with 7 grade middle school-girls and their mothers. A school-based activity educated girls about HPV and cervical cancer. A home-based activity utilized a homework assignment for girls and their mothers. Pre/post intervention surveys were completed by the girls and their mothers. Major outcomes included changes in knowledge among girls and mothers and barriers to be screened for cervical cancer among mothers. Results: Sixty-five students and sixty-three mothers completed the study. Two out five mothers were not in compliance with current screening recommendations. Identified barriers included: embarrassment (79%), poor access (56%), fear of having cancer (52%), and cervical cancer screening being an unknown procedure (46%). Forty-four percent of mothers deemed their daughters to be at risk for cervical cancer. Trusted sources of information included: doctors (97%), newspapers/television (89%), government (79%), the Internet (78%), and friends (62%). Student knowledge scores (7-point scale) improved significantly from pre- to post-intervention (4.8 vs. 5.9, p < 0.001). Knowledge scores (14-point scale) among mothers also significantly improved (11.7 vs. 12.0, p = 0.024). Conclusions: These data suggest a community-based intervention on a sensitive topic by family medicine residents can be implemented in middle schools, can improve school-girls’ knowledge about HPV and cervical cancer, and can reach their mothers. Additional research could examine whether those intending to be screened receive screening and how to reach women who still resist screening. Keywords: Early detection of cancer, Japan, Papillomavirus vaccines, Vaccination, Intervention Summary of implications of the research/article vaccination and cervical cancer screening. About two of for practicing GP’s five mothers in this rural area were not in compliance This research illustrates that a community-based interven- with cervical cancer screening. Reported barriers to tion featuring a lecture by family physicians to middle screening included: embarrassment, poor access, fear of school-girls, followed by a homework assignment for the having cancer, and cervical cancer screening being an un- girls and mothers, can increase knowledge about HPV known procedure. While these girls and mothers under- stand that HPV infection can cause cancer, confusion persisted about whether all forms of HPV infection are * Correspondence: tomoko_itou@hotmail.com; remi.japan@gmail.com linked to cervical cancer. The intervention did not in- Shiga Center for Family Medicine, 1825 Yuge, Ryuo, Gamo District, Shiga crease substantively the number of mothers intending to Prefecture 520-2501, Japan Shizuoka Family Medicine Program, Shizuoka, Japan be screened; this is likely due to high rates of intention to Full list of author information is available at the end of the article © 2014 Ito et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Ito et al. Asia Pacific Family Medicine 2014, 13:13 Page 2 of 8 http://www.apfmj.com/content/13/1/13 be screened at baseline. As virtually all mothers consider million HPV inoculations included: anaphylaxis - one case, physicians a trustworthy information source, physicians Guillan-Barre syndrome - 0.6 cases, acute disseminated en- should actively encourage daughter and mother participa- cephalomyelitis (ADEM) - 0.4 cases, though the relationship tion in these preventive services. between these symptoms and vaccination were not proven. In all, 20 cases per 1 million were rated as serious cases of Introduction pains or body convulsions, pains in joints or difficulty in Cervical cancer is the second most common cancer walking[6].Thisislessthanthe 26.0serious casesper among women between the ages of 20–49 in Japan [1]. million inoculations of Japanese encephalitis vaccine [5]. Japan had a national cervical cancer screening program With regard to the burden of cervical cancer in Japan, in a from 1982 to 1998 targeting women 40 years of age and ten-year period, about 16,000-28,000 women per year are di- older; however, this national program ended when the agnosed with cervical cancer and about 2,400-2,700 of them responsibility was transferred to local governments. The die as a result [7-9]. current cervical cancer screening recommendation in Educational efforts by health professionals have the po- Japan is to screen women 20 years of age and older every tential to enhance knowledge among adolescents and adult two years [2]. Since 2009, the Japanese government has women about cervical cancer, the purpose of screening, offered a free cervical cancer screening coupon to and the value of prevention through HPV vaccination women at the ages of 20, 25, 30, 35, and 40 [3]. Despite [3,10]. Given their role in “womb-to-tomb” care, family these recommendations and incentives, Japan has the physicians are well placed in the community for playing an lowest rate of cervical cancer screening among devel- influential role in promoting HPV vaccination and cervical oped countries [4]. cancer screening. The purpose of this research was to as- Despite an initial start with a compulsory vaccination pro- sess the feasibility of a family medicine resident-led, school- gram, Japan differs from other developed countries in the based educational intervention to increase knowledge of adoption of HPV vaccination. Human Papilloma Virus cervical cancer and the role of HPV vaccinations in middle (HPV) vaccination has been shown to be effective for pre- school-girls while indirectly increasing knowledge and cer- venting cervical cancer and began in 2009 in Japan. A com- vical cancer screening intentions in their mothers. pulsory program to have HPV vaccinations began in Japan in April of 2013; however, case reports emerged suggesting Materials and methods severe side effects of HPV vaccine. Hence, the Japanese gov- Design, setting and participants ernment withdrew the compulsory program in June, 2013. We utilized a pre-test/post-test intervention design The Japan Times [5] reported a total of 8.29 million people (Figure 1). The study took place in three middle had received HPV vaccines through December 2012. Ac- schools in the rural town of Shizuoka Prefecture, cording to a Ministry of Health, Labour and Welfare Japan in April and May, 2013. Participants included th (MHLW) panel, 1,925 cases of side effects were reported first-year female middle school students (7 grade through the end of December 2012. In the MHLW report equivalent) from the three schools and their mothers. from July, 2014, the rate of very serious side effects per one All female students and their mothers were eligible Figure 1 Study design. Ito et al. Asia Pacific Family Medicine 2014, 13:13 Page 3 of 8 http://www.apfmj.com/content/13/1/13 for inclusion; there were no exclusion criteria. This sources of information, and appropriate times to educate project was approved by the Hamamatsu Medical daughters about cervical cancer screening. This instru- School Institutional Review Board. ment required mothers about 15 to 20 minutes to complete. Mothers also completed five demographics Intervention items on age, highest educational level, personal and The project involved a two-part intervention with both family experience with cervical cancer, and history of school-based and home-based components. The school- cervical cancer screening administered pre-intervention based component lasted approximately one hour, and only. Both student and mother instruments targeted a th was comprised of a 20-minute slide presentation by two 6 grade reading level. female family physicians (TI and RT) about HPV and cervical cancer, and a 9-item worksheet filled out by middle school-girls during the presentation. It was car- Data analysis ried out using an interactive-lecture format in a school Descriptive statistics were calculated for demographic var- classroom. The content was developed to address three iables filled out by the mothers at the baseline survey. The fundamental topics: 1) the high prevalence and incidence major outcomes included changes in student knowledge of cervical cancer among young women, 2) cervical can- of HPV and cervical cancer pre- and post-intervention, cer is preventable and 3) how to prevent cervical cancer. mothers’ knowledge, attitudes and beliefs, mothers’ inten- The school-based component was reviewed with teacher tions to obtain cervical cancer screening, and differences representatives of the three participating middle schools. between mothers compliant with cervical cancer screening Any content felt by the teachers to have sexual connota- recommendations and those not compliant. Sixty-three tions was not acceptable and removed. The school mothers completed both the pre- and post-intervention teachers agreed to the final content. The home-based survey (Table 1). Two mother-daughter pairs did not an- component centered on a required homework assign- swer any questions on the post questionnaire and were ment in which the girls reviewed the worksheet they had not included in the analyses. For some instruments, par- completed with their mothers. ticipants did not answer all questions. Such unanswered questions were treated as missing values and the results Data collection reported are based on valid responses, except as indicated Pre-/post-surveys about HPV and cervical cancer screen- below for the knowledge questions. ing were administered to assess knowledge of HPV and Knowledge scores for students were computed by cervical cancer among the middle school-girls. The inves- summing together the number of correct responses on tigators distributed the pre-intervention survey three days seven applicable knowledge questions asked at both pre- before the school-based exercise with the girls. The post- and post-intervention. In cases where students missed intervention survey was distributed after the school-based answering a question (one case at pre- and one post- exercise taken by the girls, and the post-intervention sur- intervention), missing responses were treated as ‘incor- veys were collected within the following seven days. rect’ responses. Two questionnaires filled out by fathers This survey was developed using questions from previ- were dropped from the analyses since the questions were ously published surveys [11-19] and included 9 true/false designed for women. The two girls whose fathers had questions that required 5–10 minutes to complete. A completed the parent survey were included in the ana- similar instrument that differed by having more ques- lysis of student scores. All 67 students had scores for the tions was administered to the mothers that assessed pre-survey and at post there were 65 valid scores (2 stu- knowledge, beliefs about HPV and cervical cancer, as dents did not complete any of the post questionnaire). well as future intentions to be screened for cervical can- Scores could range from 0 to 7 based on responses to cer. The instrument for mothers included 20 items. This the 7 knowledge questions. Average scores were com- survey involved true/false questions (including the same pared for the 65 students who completed both surveys questions asked of the daughters), as well as additional using a paired t-test. questions that were specific to the mothers or deemed Mothers’ knowledge scores were computed by sum- not appropriate for students by the school (ie., whether ming together the number of correct responses on 14 HPV is sexually transmitted, whether having the vaccine applicable knowledge questions asked at both pre- and precludes the need for screening, and whether cervical post-intervention. As with students, a missing response cancer screening should be done regularly). Additional by any of the mothers when other questions had been questions were posed to mothers using a four-point answered was considered incorrect. Knowledge scores Likert scale addressing prevention of cervical cancer, could range between 0 and 14. The item measuring their risks of cervical cancer for their daughters in the intention to be screened in the future, “Do you intend future, barriers to cervical cancer screening, trustworthy to be screened for cervical cancer?” originally had Ito et al. Asia Pacific Family Medicine 2014, 13:13 Page 4 of 8 http://www.apfmj.com/content/13/1/13 Table 1 Mother demographics N = 63 Compliant (n = 39) Non-compliant (n = 25) Overall N (%) Age, p-value = 0.803 <=30 1 (2.6) 0 (0.0) 1 (1.6) 31-35 3 (7.9) 4 (16.0) 7 (11.1) 36-40 10 (26.3) 7 (28.0) 17 (27.0) 41-45 19 (50.0) 10 (40.0) 29 (46.0) > = 46 5 (13.2) 4 (16.0) 9 (14.3) Education, p value = 0.332 Junior High School 2 (5.3) 0 (0.0) 2 (3.2) High School 13 (34.2) 14 (56.0) 27 (42.9) College/Special School 19 (50.0) 9 (36.0) 28 (44.4) University 4 (10.5) 2 (8.0) 6 (9.5) Cervical Cancer History [n = 58], p value = 1.00 Herself 1 (2.9) 0 (0.0) 1 (1.7) Family/Relatives 1 (2.9) 0 (0.0) 1 (1.7) Friends 2 (5.7) 2 (8.7) 4 (6.9) None/Don’t Know 31 (88.6) 21 (91.3) 52 (89.7) responses of “no,”“yes, in this year” and “yes, in 2–3 Daughters’ and mothers’ knowledge about HPV and years.” This was dichotomized into “no” or “yes.” cervical cancer Regarding two change-in-beliefs questions asking about Figure 2 provides a comparison of student and mother mothers’ trust of information from multiple sources and knowledge scores. Average knowledge scores for students appropriate timing of education about cervical cancer on a seven-point scale were significantly higher from before education, the categories (strongly disagree, disagree, to after the intervention (4.8 vs. 5.9, p-value < 0.001). Simi- agree and strongly agree) were collapsed into two categor- larly, average scores for mothers on a 14-point scale for the ies (agree vs. disagree). The responses to these questions 63 mothers who completed both surveys were significantly from mothers between pre- and post- were compared higher from before to after the intervention (11.7 vs. 12.0, using the McNemar test. p-value = 0.024). The relationship between change in score for both mother and daughter was investigated by categorizing Results the change for both groups as increasing, staying the Demographics same or decreasing. Cross-tabulation was used to exam- th Sixty-five female 7 grade students completed the study ine the relationship between corresponding mother and and were either 12 or 13 years of age. Most mothers were daughter score changes. A chi-square test was not sig- over the age of 40 (60%) and all but 2 had graduated from nificant (Fisher’s Exact p-value = 0.664), indicating that a high school. Regarding personal experience with cervical change in score for students from pre- to post- was in- cancer, only one of the mothers had a personal history of dependent of change in score for mothers, i.e., increase cervical cancer, while five had a relative or friend who had in students’ knowledge scores doesn’t correspond to an had cervical cancer. At baseline 19 mothers reported that increase in mothers’ knowledge scores. they had never been screened for cervical cancer, while an- As shown in Table 2, responses to specific knowledge other 6 indicated that they had not been screened in more questions improved for most items; however, unexpect- than 3 years. Thus, 25 (40%) mothers were not compliant edly, both student and mother understanding that all with screening recommendations at baseline. Regarding HPV infections do not lead to cervical cancer decreased. perception of their daughters’ vulnerability to getting Otherwise, for students, increase in knowledge scores cervical cancer in the future, 28 (44%) respondents agreed were seen on all other questions with greatest gains in or strongly agreed that their daughters were vulnerable to understanding that HPV causes cervical cancer (44% future cervical cancer. There was no relationship between improvement), cervical cancer is asymptomatic at an agreeing/disagreeing with this statement and maternal age, early stage (32% improvement), and cervical cancer is education, cervical cancer history or intention to be preventable (25% improvement). Mother knowledge screened pre-intervention. scores were high at baseline, and increases in knowledge Ito et al. Asia Pacific Family Medicine 2014, 13:13 Page 5 of 8 http://www.apfmj.com/content/13/1/13 Figure 2 Comparison of student and mother knowledge scores pre- and post- intervention*. *Since students and mothers answered a different number of knowledge questions, student scores could range from 0 to 7, while mother scores could range from 0 to 14. Comparison on the same scale was made by dividing the score by the maximum possible (7 for students and 14 for mothers). were modest, though a clinically notable difference was a Mothers’ beliefs about barriers to cervical cancer 14 percentage point gain for understanding that safe sexual screening practices can prevent cancer. When comparing knowledge Mothers also responded to questions about barriers to cer- scores among mothers compliant with cervical cancer vical cancer screening and prevention of cervical cancer. At screening recommendations and among mothers not com- the baseline assessment, many mothers identified barriers to pliant, there were no significant differences. cervical cancer screening including: embarrassment (79%), Table 2 Correct knowledge about HPV vaccine and cervical cancer responses of students and mothers Students, N = 65 Mothers, N = 63 Pre Post Pre Post Cervical cancer is caused by HPV infection? 46% 100% 86% 97% Cervical cancer is genetic? 51% 63% 71% 81% All HPV infections lead to cervical cancer? 75% 49% 89% 76% Cervical cancer is decreasing in recent years? 83% 92% 100% 98% Cervical cancer is preventable? 72% 97% 70% 78% Cervical cancer is asymptomatic usually in early stage? 65% 97% 98% 98% Early detection of cervical cancer might save one’s life? 85% 92% 95% 97% HPV is sexually transmitted? NA NA 91% 97% If vaccinated, you don’t need to be screened? NA NA 98% 97% Screening test should be done regularly? NA NA 92% 95% HPV vaccination can prevent cervical cancer NA NA 95% 95% Safe sex (steady partner, use of condoms) can prevent cervical cancer NA NA 75% 89% Pap test can prevent cervical cancer NA NA 94% 95% Healthy lifestyle (ie., regular exercise, disciplined lifestyle, healthy diet) can prevent cervical cancer NA NA 11% 11% NA = Not asked as deemed to be too sensitive and unacceptable by the local middle schools. Ito et al. Asia Pacific Family Medicine 2014, 13:13 Page 6 of 8 http://www.apfmj.com/content/13/1/13 poor access (56%), fear of having cancer (52%), and cer- with cervical cancer screening. Identified barriers to screen- vical cancer screening being an unknown procedure ing included: embarrassment, poor access, fear of having (46%). Among mothers who were in compliance and cancer, and cervical cancer screening being an unknown mothers out of compliance with cervical cancer screen- procedure. As previous screening predicts future intention ing recommendations, there were differences in their re- to be screened, the women with greatest need are those sponses on the importance of cervical cancer screening who are not currently compliant. Close to half of mothers being an unknown procedure, with 72% of non- (44%) feel that their daughters are at risk for cervical cancer compliant mothers agreeing and only 29% of compliant in the future. For their education, mothers identify as par- mothers agreeing (p-value < 0.001). ticularly trusted sources of information their doctors and media/newspapers. Mothers’ beliefs about trustworthy sources of information Student and mother knowledge scores improved sig- and timing of education about HPV and cervical cancer nificantly from baseline to post-intervention, indicating screening that in the short term this school-based intervention Mothers answered questions about sources of trusted infor- was effective for promoting knowledge about HPV vac- th mation and beliefs about when it is appropriate to educate cination and cervical cancer screening for 7 grade girls. women at baseline assessment. Regarding sources of The magnitude of improvement was much greater for trusted information about cervical cancer, the percent indi- the students than mothers, attributable to the high base- catingstrongagreement or agreement for five sources was: line knowledge scores. It was not possible to assess long- doctors (97%), newspapers/television (89%), government term knowledge retention, nor whether the intervention (79%), the Internet (78%), and friends (62%). Mothers also actually impacted the rate of HPV vaccinations among were asked about the appropriate timing of education about these middle school-girls, nor the rate of cervical cancer cervical cancer, and at baseline, the percent indicating screening of their mothers. strong agreement or agreement for four sources was: begin- Despite high knowledge scores at baseline, 40% of the ning of junior high (83%), end of junior high (79%), high mothers were not in compliance with cervical cancer school (65%) and college or later (52%). When compared screening. This suggests that there are other factors be- pre- and post- intervention using McNemar’s test, there sides knowledge that impact these women’s decision were no differences for either trusted source of information making about whether to receive cervical cancer screen- or beliefs, an indication that the intervention did not have ing. Previous research suggests factors that may prove to an effect on these factors. be barriers to cervical cancer screening. Fetters et al. found that 12 of 19 Japanese women receiving care in a Impact of intervention on intention to receive cervical U.S. clinic approved of the U.S. style of the pelvic exam- cancer screening among those not compliant with ination and they valued such measures as using a private screening guidelines room, covering the perineum with a sheet and explain- Twenty-five mothers (40%), including 19 who had reported ing the procedures being used [20]. This contrasts with no history of cervical cancer screening and six who reported the typical style of examination in Japan where a woman no screening in over 3 years, were not in compliance with receives pelvic examinations lying on an examination Japanese screening recommendations. In the subset of 23 table in a stall with a curtain placed at the waist for priv- mothers who answered both the pre- and post-intervention acy even though her pelvis is exposed openly to staff survey, five women who had not indicated an intention to [20]. In an opinion paper, Konno et al. mentioned that be screened at baseline, changed and indicated intention to in order to make public health measures of cervical can- be screened after the intervention. A McNemar test indi- cer effective, education, environment and enforcement cated that the intervention did not significantly promote are very important, but that the Japanese cervical cancer intention to receive cervical cancer screening on those out screening environment gives the patients no control and of compliance, though sample size is small so ability to make often no privacy [3]. In related research from Taiwan, inferences is limited. A chi-squared test indicated a signifi- Wu found barriers to breast cancer screening to include: cant relationship with those who had been screened in the 1) excuses (no time, forgot, cumbersome and lazy), 2) no past being more likely to intend on being screened again need for screening, 3) modesty, 4) discomfort, 5) logis- (100.0% vs. 65.2%, p < 0.001). tics, 6) lack of information/knowledge, and 7) fear of finding cancer [11]. In their report about barriers to Discussion HPV vaccination in Asia Oceania, Garland et al. raise These data provide information about the nature of know- the barrier of reluctance to discuss issues around sex ledge about HPV vaccination and cervical cancer risk in [11]. This barrier clearly applies in Japan where medical one rural community. These findings illustrate that two out students have no routine exposure to discussions on of five mothers in this rural area were not in compliance sexuality. Few family medicine training programs in Ito et al. Asia Pacific Family Medicine 2014, 13:13 Page 7 of 8 http://www.apfmj.com/content/13/1/13 Japan even offer women’s health training [21]. Few prac- Medicine program, and Ayaka Yajima of the University of Michigan for their assistance. ticing primary care physicians provide contraceptive or prenatal [22,23]. Reluctance to have screening may also Author details reflect a sense of vulnerability, or unpleasant, negative Shiga Center for Family Medicine, 1825 Yuge, Ryuo, Gamo District, Shiga Prefecture 520-2501, Japan. Shizuoka Family Medicine Program, Shizuoka, experiences, e.g., discomfort, poor explanations in the Japan. Department of Obstetrics, Gynecology and Family Medicine, past [3,20]. Future research should explore the potential Hamamatsu University, School of Medicine, Hamamatsu, Shizuoka, Japan. barriers to, and benefits of, women seeking care for Department of Family Medicine, University of Michigan, Ann Arbor, Michigan, USA. Department of Family Medicine and Community Health, women’s health issues with family physicians. Research Division, Rutgers Robert Wood Johnson Medical School, Piscataway, There are a number of limitations to this study. While New Jersey, USA. Mori Machi Family Medicine Clinic, 387-1 Kusagaya, Mori, the educational intervention content was appropriate for Shuchi District, Shizuoka Prefecture 437-0214, Japan. improving student knowledge, it may be insufficient for the Received: 5 August 2014 Accepted: 29 October 2014 educational needs of their mothers. While there was mean- ingful increase in the number of women who intended to be screened after the intervention, it is not clear whether References the intervention was actually linked to the mothers’ inten- 1. Matsuda A, Matsuda T, Shibata A, Katanoda K, Sobue T, Nishimoto H: Cancer incidence and incidence rates in Japan in 2007: a study of 21 tions to be screened. A number of mothers reported they population-based cancer registries for the monitoring of cancer had never been screened for cervical cancer. As obtaining a incidence in Japan (MCIJ) project. Jpn J Clin Oncol 2013, 43:328–336. Pap smear is routine practice with all pregnant women, it is 2. 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Kahn JA, Ding L, Huang B, Zimet GD, Rosenthal SL, Frazier AL: Mothers' contributed to design development, advising about the intervention, intention for their daughters and themselves to receive the human interpretation of the data and final editing of the paper. MP and AS papillomavirus vaccine: a national study of nurses. Pediatrics. 2009, contributed to the data analytics, interpretation, presentation, and authoring 123:1439–1445. of the paper. BF and MF contributed to the design development, advising 16. Price RA: Knowledge and intention to participate in cervical cancer about the intervention, data analysis and presentation, and authoring of the screening after the human papillomavirus vaccine. Vaccine. 2011, paper. All authors reviewed and approved of the submitted manuscript. 29:4238–4243. 17. Wong LP: Knowledge and attitudes about HPV infection, HPV Acknowledgements vaccination, and cervical cancer among rural Southeast Asian women. We thank the students, parents and teachers of Morimachi town. We Int J Behav Med 2011, 18:105–111. appreciate the helpful advice of Drs. John W. Creswell, Paryono Paryono, and 18. Black LL, Zimet GD, Short MB, Sturm L, Rosenthal SL: Litrature review of Karl Rew. We also thank Kiyomi Ozawa of the Morimachi Educational human papillomavirus vaccine acceptability among women over Committee, Natsuko Morita and Sachiko Takeshita of the Shizuoka Family 26 years. Vaccine. 2009, 27:1668–1673. Ito et al. Asia Pacific Family Medicine 2014, 13:13 Page 8 of 8 http://www.apfmj.com/content/13/1/13 19. Marlow LA, Zimet GD, McCaffery KJ, Ostini R, Waller J: Knowledge of human papillomavirus (HPV) and HPV vaccination: an international comparison. Vaccine 2013, 31:763–769. 20. Fetters MD, Masuda Y, Sano K: Japanese women's perspectives on pelvic examinations in the United States. Looking behind a cultural curtain. J Reprod Med 2003, 48:194–200. 21. Fetters MD, Fujioka Y: なぜ、日本の家庭医学研修に婦人医療研修が含 まれるべきなのか? (Why women's health training is needed during family medicine residency training in Japan). Jpn J Fam Pract 2009, 15:44–51. 22. Kitamura K, Fetters MD, Ban N: Contraceptive care by family physicians and general practitioners in Japan: Attitudes and practices. Fam Med 2004, 36:279–283. 23. Kitamura K, Fetters MD, Ban N: Preconception care by family physicians and general practitioners in Japan. BMC Fam Pract 2005, 6:31. doi:10.1186/s12930-014-0013-0 Cite this article as: Ito et al.: A community-based intervention in middle schools to improve HPV vaccination and cervical cancer screening in Japan. Asia Pacific Family Medicine 2014 13:13. 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Journal

Asia Pacific Family MedicineSpringer Journals

Published: Nov 18, 2014

References