Review of literature is an essential component of a worthwhile study in any field of knowledge. It helps the investigator to gain information on what has been done previously and to gain information on what has been done previously and to gain deeper insight in to the research problem. It also helps to plan and conduct the study in systematic manner.

In this chapter, the investigator has presented the available research studies and relevant literature from which the strength of the study was drawn.

1. Studies related to cervical cancer

2. Studies related to HPV vaccination.

STUDIES RELATED TO CERVICAL CANCER

MiocLee,C.(1999) conducted a qualitative study with eight focus groups (number of sample=102) by using eleven question derived from the health belief model. Focus group revealed that there was misinformation and a lack of knowledge about cervical cancer. The women there fore were confused about causative factors and preventive strategies related to cervical cancer. The findings showed that major structured barriers were economic and time factors. The main psychological barriers were fear, denial confusion thinking. Participants stated that medical advice and education would influence them to undergo Pap test. Recommendations were made to reduce certain barrier and to increase knowledge and motivation.

Sheila,Twin. (2005) conducted a study among chinese women from a total sample of 467 in order to identify the knowledge about cervical cancer. Evident suggested that women knowledge about cervical cancer and preventive strategies are significant their screening practices. The need for further knowledge about the cervical screening and preventive measure was demonstrated.

HkoLiou, Xueminling. (2009) conducted cross sectional descriptive design on responses action and health promoting behaviors among rural Taiwanese women with abnormal Pap test. The result shows that nearly 14% were diagnosed as precancerous and underwent further treatment. 24%of the women took no action during the 3 month after receiving the result. As many as 96% were not aware about localized cervical cancer. These analyzed results may prove useful in developing intervention strategies to assist women with positive Pap test results to choose treatment modalities and adopted health behaviors.

STUDIES RELATED TO HPV VACCINATION

Kwan,T, et .al. (2007) conducted a cross sectional community based study to explore Chinese women’s perception of human papilloma virus vaccination and their intention to be vaccinated . A total of 1450 ethnic chinese women aged 18 and above who attended the health centers. The result shows about 38% of participants (n=527) had heard of HPV and about 50% (n=697) had heard of vaccination against cervical cancer. 88% of the participants(n=1219) indicate that they would likely to be vaccinated. Majority of the participants believed that sexually experienced women should be vaccinated; while27%opposed vaccinating sexually naïve women. study suggested that HPV infection was perceived to be stigmatizing to intimate family and social relationships, despite misconception and a grossy inadequate knowledge about HPV and HPV vaccination,

NubiaMunoz, et .al. (2007) conducted study among 17, 622 women aged 15-26 years who were enrolled in one of two randomized, placebo-controlled, efficacy trials for the HPV6/11/16/18 vaccine (first patient on December 28, 2001, and studies completed July 31, 2007). Vaccine or placebo was given at day 1, month 2, and month 6. All women underwent cervico vaginal sampling and Pap testing at day 1 and every 6-12 months there after. A result shows that vaccination was up to 100% effective in reducing the risk of HPV16and 18 related high-grade cervical, vulvar, and vaginal lesions and of HPV 6 and 11-related genital warts. In the intention-to-treat group, vaccination also statistically significantly reduced the risk of any high-grade cervical lesions (19.0% reduction; rate vaccine = 1.43, rate placebo = 1.76, difference = 0.33, 95% confidence interval [CI] = 0.13 to 0.54), vulvar and vaginal lesions (50.7% reduction; rate vaccine = 0.10, rate placebo = 0.20, difference = 0.10, 95% CI = 0.04 to 0.16), genital warts (62.0% reduction; rate vaccine = 0.44, rate placebo = 1.17, difference = 0.72, 95% CI = 0.58 to 0.87), Pap abnormalities (11.3% reduction; rate vaccine = 10.36, rate placebo = 11.68, difference = 1.32, 95% CI = 0.74 to 1.90). Conclusion of the study is High-coverage HPV vaccination programs among adolescents and young women may result in a rapid reduction of genital warts, cervical cytological abnormalities.

Infectious Disease Obstetric Gynecology journal. (2006) suggested that Vaccines which protect against infection with the types of human papillomavirus (HPV) commonly associated with cervical cancer (HPV 16 and 18) and genital warts (HPV 6 and 11) are expected to become available in the near future. Because HPV vaccines are prophylactic, they must be administered prior to exposure to the virus, ideally during preadolescence or adolescence. The young age of the target vaccination population means that physicians, parents, and patients will all be involved in the decision-making process. Research has shown that parents and patients are more likely to accept a vaccine if it is efficacious, safe, reasonably priced, and recommended by a physician. Widespread education of physicians, patients, and parents about the risks and consequences of HPV infection and the benefits of vaccination will be instrumental for fostering vaccine acceptance.

Andrea Licht,S, et. al. (2009) conducted study on HPV vaccination. The aims of this study were to assess HPV vaccination rates and to examine whether knowledge and risk perceptions regarding HPV were associated with the reported use of the HPV vaccine among female college students. A cross-sectional design was used among 406 women aged 18-26 years were recruited at two public universities and completed a self-administered survey. Respondents who reported having received at least one dose of HPV vaccine were classified as ‘vaccinated’ (n=177, 43.6%). Responses, stratified by the receipt of HPV vaccine, were compared using descriptive statistics and multivariate models. Results based on multivariate logistic regression modeling, 18-year-old women were approximately four times more likely to report use of the HPV vaccine compared with respondents aged 19-26 years. Respondents who correctly indicated that HPV caused genital warts were 1.85 times more likely to have received at least one HPV vaccine. African American and Asian women were each less likely to be vaccinated compared with white women. Risk perception was not significantly associated with vaccine uptake, however, the majority of respondents failed accurately to recognize their high risk of both acquiring and transmitting HPV. These findings suggest knowledge deficits and misperceptions about HPV risk as potential themes for educational campaigns encouraging the greater use of the preventive HPV vaccine among this subgroup

Allison Friedman,L. (2004) suggested that genital human papilloma virus (HPV) infection is the most common sexually transmitted virus in the united States, causing genital warts, cervical cell abnormalities, and cervical cancer in women. To inform HPV education efforts, 35 focus groups were conducted with members of the general public, stratified by gender, race/ethnicity, and urban/rural location. Focus groups explored participants’ knowledge, attitudes, and beliefs about HPV and a hypothetical HPV vaccine as well as their communication preferences for HPV-related educational messages. Audience awareness and knowledge of HPV were low across all groups. This, along with an apparent STD-associated stigma, served as barriers to participants’ hypothetical acceptance of a future vaccine. Although information about HPV’s high prevalence and link to cervical cancer motivated participants to learn more about HPV, it also produced audience fear and anxiety. This research suggests that HPV- and HPV-vaccine-related education efforts must be approached with extreme

Raley, JC. (2004) suggested that Human papilloma virus (HPV) is the causative agent of cervical neoplasia and genital warts. A vaccine has recently been developed that may prevent infection with HPV. Vaccination for HPV may become a routine part of office gynecology. Researcher surveyed members of the American College of Obstetricians and Gynecologists (ACOG) to determine their attitudes to HPV vaccination. A survey was sent to Fellows of ACOG to evaluate gynecologists’ attitudes. Vaccine acceptability was analyzed by using 13 scenarios with the following dimensions and respective attributes: age of patient (13, 17 and 22 years); efficacy of vaccine (50% or 80%); ACOG recommendation (yes or no); and disease targeted (cervical cancer, warts or both). Each scenario was rated by means of an 11-point response format (0 to 100). Responses were evaluated using conjoint analysis. Results of 1200 surveys that were sent out, 181 were returned and included in our analysis. ACOG recommendation was considered the most important variable in vaccine distribution (importance score = 32.2), followed by efficacy (24.5), age (22.4) and, lastly, disease targeted (20.9). Of these variables, higher efficacy was favored; preference was given to age 17 years, with a strong disinclination to vaccinate at age 13 years; and protection against cervical cancer, or genital warts, or both. Demographic characteristics of the gynecologists (i.e., age of physician, gender, and practice setting and community size) did not play an important role in the decision to recommend vaccination. Professional society recommendation is important for acceptability of a potential HPV vaccine. Gynecologists are willing to include this vaccine in their practice.

Chun Chao, et. al (2007) conducted study among 34,193 female who initiate HPV vaccination. The aim of the study was to examine the rate and correlate the completion of HPV vaccination. The result shows that the completion rate was 41.9% among age group between 9- to 17-year and 47.1% in the 18- to 26-year. Black race – 95% confidence interval and lower neighborhood education level were associated with lower regimen completion. A history of sexually transmitted diseases, abnormal Pap test results, and immune-related conditions were not associated with HPV vaccination regimen completion.

Caron, et. al. (2008) conducted a cross sectional study among college women, the study reveals that cervical cancer is primarily caused by the human papillomavirus (HPV) and is the second most common cause of cancer-related mortality among women. Purpose: College women may be at risk for contracting HPV based on their sexual behavior. An exploratory analysis was conducted, following the release of the HPV vaccine, Gardasil[R], the am of the study is to (1) determine awareness of HPV and Gardasil[R], (2) assess attitudes, behaviors, and beliefs about the HPV vaccine, (3) identify information sources that college women are accessing. Methods: A cross-sectional study of college women (n=293) enrolled in a Northeastern university voluntarily completed a self-administered questionnaire regarding knowledge, attitudes, behaviors, and beliefs about correlations, and paired sample t-tests. Results: Sexually active respondents would recommend the HPV vaccine to others and disagree that HPV vaccination would encourage risky sexual behavior. Yet, “need more information” is the predominant reason respondents would not get the HPV vaccine if it were offered for free. Discussion: Correlations are identified on how self-reported knowledge influenced attitudes, behaviors, and beliefs regarding the HPV vaccine. These findings should assist health educators in developing integrated public health education efforts for HPV vaccination that are targeted towards this at-risk population.