Knowledge and Attitude towards Human Papilloma Virus Infection, Vaccines, and Cervical Cancer Prevention among School Students in Kano, Nigeria

The rising cases of human papillomavirus (HPV) infection and cervical cancer cases in Nigeria are alarming. Only a few studies have looked at secondary school students in Nigeria's understanding of HPV infection and vaccine acceptance, whereas earlier studies have mostly focused on screening. In this study, 400 students from two secondary schools in Kano State, Nigeria, were engaged with the aim of assessing their level of knowledge and attitudes regarding HPV infection. The study further seeks to understand the respondent's opinion on HPV vaccination and sensitize them to the health effects of HPV infection, thereby communicating the findings to the authorities concerned with policy making. The study revealed that only 128 (32%) and 142 (35.5%) respondents have knowledge about HPV and cervical cancer, respectively. Furthermore, none of the respondents were administered the HPV vaccine, with 81% of them not ready to take the vaccine. It was observed that the majority of the respondents (91%) believed that early hospital visits could help in mitigating HPV or cervical cancer cases. Following their sensitization, the respondents were observed to have different levels of satisfaction, ranging from very satisfied and satisfied to not satisfied. Effective awareness creation amongst students as well as parents is therefore essential in HPV vaccination projects, as well as in reducing the burden of cervical cancer in Nigeria.


Introduction
Globally, human papillomavirus (HPV) infection is one of the most prevalent sexually transmitted infections. A lifetime exposure to at least one HPV type occurs in more than 50% of sexually active females. Women of all ages can contract HPV, but those between the ages of 20 and 24 have the highest incidence of infection [1,2]. Almost all sexually active men and women will obtain at least one type of HPV at some point in their lives. Each year, a very high number of new HPV infections in both men and women are reported in Africa. In men, some certain strains of HPV have been found to cause diferent types of cancer such as cancer of the anus, penis, throat, and mouth [3]. Te majority of genital HPV infections are asymptomatic and transitory, and they disappear on their own without producing any disease [4].
Based on the possible risk attached to the disease's progression to malignancy, as well as warts developed in the genital area, these HPV types are categorized as high-or lowrisk HPVs. High-risk HPVs consist of HPV16 and HPV18, while HPV types 6 and 11 are low and are mostly associated with genital warts. Cervical cancer, especially the one caused by HPV types (16 and 18), constitutes up to about 70% of cases of all cervical cancers [5].
HPV was found to have a high instance among developing and under-developing countries mainly due to the weak health care system. Tis might be in connection with the high rate of maternal and child mortality. Over 90% of cases of cervical cancer occur in Africa, with an estimated 569,847 new cases and 311,365 deaths each year [6]. HPV vaccines have the potential to prevent nearly 70% of invasive cervical cancer in women worldwide [7]. Women who have not received the HPV vaccine are at risk of contracting the virus. Given that HPV is the greatest prevalent STD, it is critical that all women are informed about the advantages of vaccination and the hazards associated with not receiving it. Inadequate instruction and understanding regarding the dangers of HPV and the consequences of not getting immunized could result in permanent health difculties from HPV [1,8].
Studies have indicated that in various African nations, the signifcance of understanding HPV infection and the level of public acceptability of vaccinations vary from low to high. In Africa, 8-17 kids are heavily involved in vaccination programs, which primarily work to avoid infantile illnesses [9]. Terefore, a program to prevent cervical cancer will be more successful if students are aware of the infection, have an understanding of it, and develop a positive attitude toward HPV vaccination. In Nigeria's understanding of HPV infections, including vaccine acceptability, only a few studies have looked at secondary school students, whereas earlier research has mostly focused on screening. However, one of the most crucial steps for the prevention and treatment of cervical cancer is increasing knowledge and persuading individuals to have a favorable attitude toward the HPV vaccination [1]. Tis study aims to access the knowledge and attitude toward HPV infection, their vaccines, and cervical cancer prevention among secondary school students in Kano, Nigeria.

Study Design.
A cross-sectional study focused on two schools was carried out in Kano (Figure 1), Nigeria, between the 5 th of March and the 27 th of August, 2022.

Sampling Technique.
A random sampling technique was employed among each respondent that meets the inclusion criteria.

Study
Population. Secondary students aged 10 and above.

Sample
Size. Using the formula (n) � Z1 − α 2 /2P(1 − P)/d 2 and a prevalence of 11.1% as reported by Chigozie et al. [2], in a study conducted among female students at the University of Lagos, Lagos, Nigeria, a sample size of (n) � 150 was calculated. Te sample size was approximated to be 200 for each of the two schools, to give a total sample size of 400 in all two schools.
2.6. Inclusion Criteria. Inclusion criteria were as follows: (i) Students whose consent was sought and agreed to participate (ii) Girls aged 10 and above 2.7. Exclusion Criteria. Exclusion criteria were as follows: (i) Students whose consent was sought and agreed not to participate (ii) Girls below 10 years 2.8. Ethical Approval. Ethical approval was obtained from each of the schools before the commencement of the study, with the agreement to communicate the fndings of the study to the school's management for efective policy making. Consent of each participant was sought for prior to their engagement in the study.

Statistical
Analysis. Data obtained were analyzed using SPSS version 25 and presented in percentages.

Results and Discussion
3.1. Results. Te respondents from the two schools (Professor Hafsat Abdullahi Ganduje (PHAG) Secondary School Gyadi-Gyadi and Government Girls Secondary School (GGSS) Gandu) were accessed on the level of knowledge and attitude towards HPV and vaccine acceptance (Table 1). In this regard, respondents that choose "No" were observed to have the highest response.
Te respondents were assessed on the risk factors (Table 2) that may be linked to HPV among the respondents. Tey were observed to stand a very low risk of contracting HPV infection as many risks of HPV including signs were found not to be associated with the majority of the respondents.
Te demographic characteristics of the respondents (Table 3) shows that the majority of the respondents are within the age category of 15-19 years of age, 99% did not marry, and with 46% were engaged in trading during holidays.
Key points that relate to HPV and cervical cancer were used to sensitize students to, as well as the practice of healthy lifestyles in order to prevent themselves from contracting deadly HPV infections. Tis was followed by (Table 4) by their feedback on their level of satisfaction. Te students were observed to have much level of satisfaction following the conclusion of the sensitization.

Discussion of Results.
Tis study shows that the majority of the respondents do not have basic knowledge about both HPV infections and cervical cancer (Table 1), with only 32% and 142 (35.5%) of the respondents having knowledge about HPV and cervical cancer, respectively. None of the respondents were administered the HPV vaccine, while 81% of the respondents are not ready to be administered the HPV vaccine. Furthermore, the majority (91%) of the respondents believed that early hospital visits could help in mitigating HPV or cervical cancer cases. HPV is one of the most widespread sexually transmitted diseases in the world [4,11]. People's negative perception of the vaccine as well as the means of disease spread might be the guiding factor behind the vaccine rejection. Furthermore, the less level of awareness among healthcare providers might be the reason there is less level of awareness [12][13][14].
Tis study also fnds out that none of the respondents have conducted any laboratory tests on HPV infection or cervical cancer. Only 41% (166) and 13% (53) ( Table 2) of the respondents had some history of the presence of genital warts/skin lesions or any pain in the genital area and a history of experiencing any form of vaginal discharge respectively. On the history of experiencing any infection associated with the genital area or urinary tract and unusual bleeding in the genital area, only 91 (23%) and 14 (4%) were recorded, respectively. On the history of experiencing frequent stomach pain, the family history of any illness associated with excessive genital bleeding, and the family history of any member ever been diagnosed with cancer, only 179 (45%), 71 (17%), and 23 (6%) of the respondents were found to have a level of connection with it. Tis made the respondents to stand a lower risk of contracting HPV infection, as most of the early signs and symptoms of HPV infection were found not to be associated with the respondents, respectively. Te knowledge of the risk factors of HPV was found to be higher in countries that have existing HPV control strategies, which include sensitizations in rural communities, hospitals, as well as among school students [8,15,16].
Te result further shows that the majority of the respondents 265 (66%) were within the 15-19 years category, with none falling in the 25 years and above category (Table 3). Regarding marital status, 396 (99%) of the respondents are single, with only 1% of them being married. Te majority (46%) of the respondents engaged in trading during their holidays, with very few (22%) of them not engaged in any occupation during the period of their holidays. PHAG Gyadi-Gyadi had the least number of respondents 3 (1.5%) with a history of pregnancy, while GGSS Gandu had 7 (3.5%). However, based on the number of children of the respondents, 398 (99.5%) had no children, with only 2 (0.5%) having 1-3 children. Considering the high number of respondents that are not married and the less number of children among the very few that are married, these might be in connection with the less or absence of any knowledge about the existence of HPV and cervical cancer, considering the increasing level of awareness created among expectant or nursing mothers during their visit to hospitals. Diferent research studies have stressed the importance of the spread and detection of HPV in children, infants, and    Advances in Virology women. Furthermore, several research fndings have demonstrated that HPV can be spread to infants from their mothers, especially during childbirth, with high chances of infection with the high-risk HPV strains [17][18][19].
Following the conclusion of the sensitization (Figures 2  and 3) and the collation of feedback, the respondents were observed to have diferent levels of satisfaction ranging from very satisfed and satisfed to not satisfed. In the two schools, PHAG Gyadi-Gyadi was observed to have a higher level of respondents who are satisfed with the level of awareness created (Table 4). Tis might be due to the nature of the two schools: PHAG Gyadi-Gyadi is a science-based school, whereas Government Girls Secondary School Gandu is mixed, having students of Science, Arts, and Management backgrounds. Sensitization questions that got the highest level of satisfaction are "Can women get HPV (97%), What is HPV infection (91%), Is HPV curable (91%), Does HPV cause cancer (86%), what is the risk of cervical cancer after HPV infection (89%), and Can HPV be transmitted from the mother to the baby during pregnancy (86%);" this might be in a connection that the questions are not tricky and difcult to comprehend by the respondents. Furthermore, the level of satisfaction obtained among the respondents is actually encouraging, especially for the fact that this is the frst time sensitization on cancer was carried out in the two schools. In Table 1, research question (iv) explained the number of participants that are willing to take the vaccine which was very less, as the majority of the respondents were of the opinion that they will not take the vaccine possibly as a result of the unsure of its safety and efectiveness. Before the sensitization, respondents ready to take the HPV vaccine was only 49 and 27 from PHAG and GGSS, respectively. Whereas after the sensitization, there is an increase in the number of vaccine acceptance, as well as willingness to take the vaccine increases (Table 4 research question (xv)). Tis was possibly as a result of the sensitization which makes them well-informed of the importance of the vaccine in the prevention of HPV infections. Moreover, conducting public talks, discussions, and\or awareness campaigns on diseases that has to do with the genital area is actually something very new and unwelcoming especially in Kano State, a core Muslim state located in the northern part of Nigeria with the Hausa tribe as the majority. Tere is no doubt that this plays a key role in keeping the majority of the populace illinformed, especially those from rural areas on various means of protection, prevention, and disease treatment. Furthermore, the traditional view of limiting HPV and cervical cancer disease transmission to only via sexual intercourse needs to be addressed as the literature survey reveals many diferent routes of disease transmission, especially blood transfusion, sharp objects, along with other contact with blood or bodily fuids [6,20,21]. Te fndings of this study were as well communicated with the school authorities and the Kano State Ministry of Health for efective policy making.    Advances in Virology

Conclusions
Tis research work employed a total of 400 students attending Professor Hafsat Abdullahi Ganduje Secondary School Gyadi-Gyadi and Government Girls Secondary School Gandu, Kano State, Nigeria. Te study revealed that female students at the secondary school of Kano often had little understanding of or perception of their susceptibility to HPV infection and disorders connected to HPV. Furthermore, the majority of the respondents are ignorant of HPV, cervical cancer, and various means of disease transmission. Furthermore, most of the respondents are not ready to be administered with vaccines. Considering the high level of satisfaction among the respondents following sensitization on some important means of disease spread, control, and the urgent need to see a doctor whenever some signs associated with risk factors are seen, one cannot overstate the need for developing an efective HPV education program to close the knowledge gap.

Recommendation
(i) Tere is a need for parents to engage in creating awareness on preventive measures for all sexually transmitted diseases, with HPV inclusive among their female children (ii) Tere is a concern among parents that HPV vaccination usually leads to a higher level of sexual activity among adolescents. For this reason, adequate orientation needs to be made among parents. (iii) Sexual health education should be introduced in secondary schools with a view to educating the populace (iv) For a successful HPV vaccination project in Nigeria, there is the need to carry out both traditional leaders, religious leaders, local radio, and TV stations to create awareness amongst parents and the general populace with a view to dispel the negative public views regarding HPV vaccination.

Data Availability
Te data used to support the fndings of this study are included within the article.

Conflicts of Interest
Te authors declare that there are no conficts of interest. Advances in Virology 9