Assessment and interventions for HPV and cervical cancer

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Assessment and interventions for HPV and cervical cancer

Material Information

Title:
Assessment and interventions for HPV and cervical cancer
Translated Title:
Evaluación e intervenciones para el VPH y el cáncer cervical
Creator:
Jones-Goodrich, Rose
Saryee, Ethel
Tewell, Mackenzie
Triana, Taylor
Publication Date:
Language:
Text in English

Subjects

Subjects / Keywords:
Cervix uteri--Cancer
Cuello uterino--cancer
Costa Rica--Puntarenas--Monteverde--Monteverde Zone
Costa Rica--Puntarenas--Monteverde--Zona de Monteverde
Community Health 2011
Salud comunitaria 2011

Notes

Abstract:
This research assesses the knowledge of women regarding HPV and cervical cancer through free listing activities and survey assessment. Results were used to educate women on misconceptions, transmission methods, symptoms, and prevention strategies related to HPV. ( English,Español,,,,,,,, )
Abstract:
Esta investigación evalúa el conocimiento de las mujeres en relación con el VPH y el cáncer de cuello uterino a través de actividades gratis en los listados y la evaluación de la encuesta. Los resultados se utilizan para educar a las mujeres sobre las ideas falsas, los métodos de transmisión, los síntomas y las estrategias de prevención relacionadas con el VPH.
General Note:
Student affiliation: University of South Florida

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Resource Identifier:
M38-00088 ( USFLDC DOI )
m38.88 ( USFLDC Handle )

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U NIVERSITY OF S OUTH F LORIDA M ONTEVERDE I NSTITUTE A SSESSMENT AND I NTERVENTIONS FOR HPV AND C ERVICAL C ANCER A WARENESS 2011 R OSE J ONES G OODRICH E THEL S ARYEE M ACKENZIE T EWELL AND T AYLOR T RIANA

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INTRODUCTION According to the World Health Organization WHO 2010 the incidence of cervical cancer in Costa Rica is 17.5 per every 100,000 women compared to the average global incidence of 15.3 pe r every 100,000 women iv Among Costa Rican women, it is the second most common cancer and the most commonly diagnosed cancer among women aged 15 44 WHO 2010:iv An estimated 1.53 million women in Costa Rica are already infected with some form of H uman Pap illoma Virus HP V WHO 2010:iv Every year, around 403 women are diagnosed with cervical cancer and 158 will die from it WHO 2010:iv The rates of HPV infection and cervical cancer are growing quickly and WHO estimates that there will be 609 new cases and 275 deaths in 2025, an increase of 113% among women over 65 and 35% among women under 64. This research was advised by faculty at the Clnica de Santa Elena who had concerns over the local rates of HPV and the barriers between young women at risk for contracting HPV and information about the virus. RESEARCH OBJECTIVES Objective 1: To assess the knowledge of women regarding HPV and cervical cancer through free listing activities and survey assessment. Objective 2: To educate women on misconceptions, transmission methods, symptoms, and prevention strategies related to HPV. Objective 3: To develop a toolbox consisting of a poster, game, and informational sheet for community health educators from the clinic for future use in the community. LITERATURE REVIEW HPV is a sexually transmitted infection with over 150 strains, two of which are associa ted with cervical cancer types 16 and18 Castellsague, et al. 2007:v Only a small

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percentage of those who become infected with HPV develop cervical cancer because 90% of HPV cases are naturally eliminated by the immune syst em Braun and Gavey 1999:203 HPV also causes genital warts, but these strains types 6 and 11 are unassociated with cervical cancer CDC 2010:1 Other factors found to increase chances of cervic al cancer development include tobacco use, hormonal birth control use, greater number of childbirths and a compromised immune system Castellsague, et al. 2007:v HPV awareness in the United States has increased significantly since 2006 due to a heavily marketed vaccine, Gardasil and a lesser known vaccine, Cervarix that both protect against strains that cause cervical cancer Haber, et al. 2007:325 A 2007 clinical trial was conducted with 7000 Co sta Rican women ages 18 to 25 in the province of Guanacaste testing the Cervarix vaccine as both a prophylaxis and as a treatment in those already infected with HPV Markowitz 2007:805 Despite this large study, HPV and vaccin e awareness among Costa Ricans remain limited. Doctor Luis Guillermo Ledesma Izard, Director of Hospital Nacional de las Mujeres, reports that HPV vaccines are not available through the Costa Rican health care system, the Caja Costarricense de Seguro Soci al CAJA, but are available through private health institutions. METHODS In the initial phase of this project, the population and research direction were identified through a meeting with Novelty Castro, a nurse at the Clinica Santa Elena. Data collecti on was conducted in multiple settings in Monte Verde region including the cities of Monteverde, San Luis, and Santa Elena. A toolkit consisting of three materials informational sheet, interactive game, and poster for the clinic was also constructed for use and distribution by the clinic.

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Population and Sampling: Participant recruitment was conducted through the aid of the Monteverde Institute MVI staff, resulting in both convenience and snowball sampling. Criteria for participation included being a female and a resident of the region. Initially, women between the ages of 15 and 30 were chosen to be the focus of the assessment; however due to sample size concerns, surveys were imparted to women outside of the target age range. The final sample age dis tribution is as follows: Age 15 19 Age 20 29 Age 30 and above Age not reported 41.6% 33.3% 21.6% 3.3% 25 20 13 2 Additional relevant demographic information about our population includes 40% of the women had children, and 86.7% of the women reported attending colegio high school. Data Collection: Our preliminary information gathering consisted of informal interviews with female members of homestay families in Santa Elena, MVI faculty, and other community members in order to asses knowledge of HPV and cervical cancer, as well as to understand how knowledge is disseminated to young women. A preliminary focus group with three young women aged 15, 16, and 17 was held in conjunction with a free listing activity; participants were asked to list answer s that came to mind when prompted by questions in order to identify levels of knowledge regarding cervical cancer knowledge and HPV transmission, prevention, and misconceptions. A survey consisting of 26 questions open ended, close ended, dichotomous stru ctured, and Likert formatted questions was administered to women of all ages APPENDIX A. Questions were

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adapted from the prompts developed for the free listing activity, various information sites, and previous questionnaires imparted at MVI. The survey was administered at diverse locations in the area. A final focus group was conducted at Colegio Tcnico Profesional de Santa Elena CTPSE with female students in 9th and 11th grade. Surveys were administered to these two student populations. Ninth graders offered critique of the toolbox materials we created. To fulfill the objectives and answer research hypotheses, mixed methods were used. A total of 60 participants were used in SPSS analysis. Basic descriptive statistics wer e conducted in SPSS. Furthermore, analyses included chi squares for categorical variables and correlations for continuous variables to understand relationships between hypothesized variables. QUALITATIVE ANALYSIS In the first focus group n=3, ages 15 17, the girls€ responses largely fell in line with our advisor's assertions that young women aged 15 to 20 were not receiving adequate sex health education in school, and lacked education resources for H PV and other STIs. Our participants€ opinions about their sexual education matched their limited knowledge; they reported their classes lacked rigor and few students took it serious ly The girls were concerned with a lack of privacy when visit ing the clinic with their parents, while completing a Tamizaje a questionnaire given to all youth who visit the clinic which assessed risk behaviors including sexual practices. One girl repeatedly used the word  estrs ‚ stress to describe her experien ce of going to the clinic with her mother, who looked over her shoulder while she answered private questions Based on this, we included questions in our survey concerning what age participants thought it appropriate to attend cl inic visits alone. We were unable to discern a clear answer from either the clinic or participants. Though they did

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not stigmatize gynecological exams, they expressed fear and apprehension about having to get them, and were concerned about P ap smears bein g painful. Our survey identified many themes, including reiterating the need for more detailed information about HPV, its symptoms and its relation to cervical cancer. Participants most commonly missed questions demonst rated they were not aware that HPV can b e transmitted via skin contact, that the majority of cases have n o symptoms, and t hat there is no cure to rid the body of the virus. On average, we found that participants waited 5.37 years between their first sexu al experience and their first Pap smear. We believe this significant gap in time is a potential point of intervention for local clinics, and may be related to young women€s confusion about what age they are able to visit the clinic alone. If this age was clarified and potentially lowered, girls with early sexual debuts may feel more secure in obtaining their first Pap smear. In relation to first sexual experience, community perceptions of age at sexual debut were considerably different from actual repor ted ages of first sexual experience. Women believed girl s were having sex at an average age of 13.68, yet participants reported 17.87 years for their first sexual experience. Our group is hesitant to assign meaning to this discrepancy, but these numbers c ould provide insight if surveyed with a larger sample size. In terms of sexual health education, clinics, family, and charlas were mentioned the most frequently as sources of information, but multiple times we were told that these resources needed suppleme nting. Specific suggestions are discussed shortly. The second focus group, which consisted of nine 9th grade girls, critiqued the materials in our toolbo x: the cervical cancer awareness poster and the information sheet, then they piloted our game. The poster targeted women receiving a Pap smear, and was designed for placement on

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the ceiling above the patient exam table for visibility during gynecological visit APPENDIX B. The informational sheet was comprised of HPV and cervical cancer information and prevalence rates included a comic strip insert designed by group members APPENDIX C. Finally, the girls played the game designed by the group, which was created to assess knowledge and educate students through the identification of true and false statements APPENDIX D. Feedback on our materials was overwhelmingly positive. They appreciated the simple, straightforward design and delivery of information on the poster and information sheet. They all agreed STI l iterature was too scientific‚ and they desired basic‚ information that was not boring. They also reported not knowing the majority of the facts we presented to them, further confirming the need for these materials. Finally, the girls play ed our game, al l very excited to place their phrase on the board after discussing; around 7 of the phrases were incorrectly placed. This allowed us an opportunity to educate and once again reiterating the necessity of clear, detailed HPV and cervical cancer facts. Our community advisor Novelty Castro provided additional feedback about our materials. She believed the items we cre ated could be utilized by the clinic, and only suggested a change in the amount of text on the poster. Because women do not read posters much, she thought our message should be brief and in a bullet point formation. We made these adjustments on the final p roduct. Our research findings and materials were also presented to the community in San Luis. One of the comments we received was that materials like the information sheet helped parents discuss issues of sexual healt h with their children, making this less of a taboo subject. One attendee also discussed the topic of HPV in male sexual health and the lack of information available.

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QUANTITATIVE ANALYSIS To test hypotheses, survey data w ere compared within two age gr oups of women below thirty and above thirty. T tests and an ANOVA test were run to identify if there were differences between the age groups. The homogeneity of variances or Levene€s statistic was found to be significant for all knowledge related questions phrase questions; therefore the Brown Forsythe statistic was used as a robust test statistic with the ANOVA test. These tests demonstrated that there was no significant difference between age groups related to knowledge questions. Furthermore, when the data w ere divided into three age stages ages 15 19, 20 29, and 30+ the ANOVA and Brown Forsythe were also found to be insignificant even though the tests of homogeneity identified that the variables were not homogenous. Hence, the first two hypotheses that women whom are older will have more awareness of HPV resulting from more contact with medical facilities and staff, and that women with children would have more awareness and information were not found to be statistically significant. Figure 1. ANOVA Brown Forsythe: HPV/cervical cancer awareness by age groups Statistic df1 df2 Significance HPV & cervical cancer are the same 0.913 2 41.853 0.409 HPV is passed even with a condom 0.102 2 30.074 0.903 HPV is transmissible via skin 0.734 2 22.39 7 0.491 HPV has no symptoms 0.907 2 32.911 0.414 Only women get HPV 0.264 2 34.664 0.770 Only promiscuous people get HPV 0.570 2 26.562 0.572 It is possible to cure HPV 1.441 2 34.737 0.250

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Figure 2. Independent Samples Test: Knowledge of HPV an d cervical cancer, women with and without children t test for Equality of Means t df Sig. 2 tailed HPV & cervical cancer are the same 0.273 48 0.786 0.273 47.224 0.786 HPV is passed even with a condom 1.363 41 0.180 1.362 40.758 0.180 HPV is transmissible via skin 0.1305 46 0.198 0.1234 32.174 0.226 HPV has no symptoms 0.540 49 0.592 0.532 42.789 0.597 Only women get HPV 0.795 50 0.430 0.783 44.102 0.438 Only promiscuous people get HPV 1.169 50 0.248 1.117 36.616 0.271 It is possible to cure HPV 0.683 45.973 0.498 The final hypothesis stating that younger women would have more time between their sexual debut and first Pap smear was tested by conducting correlations and was found to be significant at the .01 level T 27= 397, p=.01. This suggests that women initiating sexual intercourse at a young age were taking longer to get their first Pap smear. Figure 3. Correlation, Kendall's tau Time between sexual debut & first Pap Age at sexual debut Time between sexual debut & first Pap Correlation Coefficient 1.000 3.97 Sig 2 tailed 0.010 N 27 27 Age at sexual debut Correlation Coefficient 3.97 1.000 Sig 2 tailed 0.010 N 27 53.000 DISCUSSION

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Our exploratory analysis identified that the survey data correlations supported our hypotheses. There was a positive significant correlation between age at first P ap smear and years between age at sexual debut and first P ap smear T 27 = .711 p= .000 meaning that the older a participant was at the age of sexual debut the longer they waited to get a P ap smear. Similarly, this means that the younger a woman was the shorter the time she waited before getting a P ap smear. There was also a positive significant correlation between current age and age at first P ap smear T 25= .495 p= .000. This was analogous because it supported the previous correlation that the younger the woman the less time was spent between sexual initiation and gett ing a P ap smear. This was also comparable to the other positively correlated variable. These findings were contrary to our hypotheses that stated that younger women were postponing P ap smears due to fear of discussing their health issues in front of the ir mothers. One significant inverse relationship was calculated between age at sexual debut and years between age at sexual debut and P ap smear, meaning that the younger a girl was at initiation of sex the longer time she waited before going to get a P a p smear T 27= .397 p= .011. These findings however must be further attempted with a representative sample as the sample was convenience and snowball, and the non parametric Kendall€s tau was calculated. LIMITATIONS This study was an ex ploratory study and did not reach survey saturation due to time constraints. Similarly, as a result of course length convenience and snowball sampling were utilized This type of sampling also resulted in unequal distribution of age and residencies. There fore the data cannot be generalized or considered representative of the whole population. Further limitations for this study included literacy levels and comprehension ability of participants taking the survey.

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RECOMMENDATIONS After assessing the results of our data collection, including the survey, focus groups, and community feedback, we complied a list of suggestions from the community. The clinic suggested that the high schools needed a sexual education program that was more structured, as well as mor e dynamic and didactic in nature to better communicate information about sexual health. Individual participants also mentioned the need for charlas with specialists, the need for parents to impart more information about sexual health to their children and trust them, and expressed concerns about the reliability and timeliness of the C aja in providing clinical test results and feedback. In addition to suggestions from the community, we created our own suggestions based on qualitative and quantitative data analysis. Th ese s uggestions include : 1 young women€s need for increased privacy at the clinic, particularly when complete the Tamizaje and during the pre consultation, 2 a educational program that focuses on empowering young women to make their o wn decisions regarding sexual health, 3 an emphasis on receiving P ap smears soon after a young women€s first sexual experience, and 4 educating young men about HPV, as men play a major role in the transmission of this virus. REFERENCES Braun, Virginia, and Nicola Gavey 1999 "Bad Girls" and "Good Girls"? Sexually and Cervical Cancer. Women's Studies International Forum 222:203 213. Castellsague, X., et al. 2007 HPV and Cervical Cancer World 2007 Report. Vaccine 25Suppl 3:C1 C26. CDC 2010 Fact Sheet: G enital HPV. Pp. 1 2. Atlanta, GA: Centers for Disease Control and Prevention. Haber, Gillian, Robert M. Malow, and Gergory D. Zimet 2007 Editorial: The HPV Vaccine Mandate Controversy. Journal of Pediatric Adolescent Gynecology 20:325 331. Markowitz, Laur i E.

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2007 Editorial: HPV Vaccines -Prophylactic, Not Therapeutic. Journal of the American Medical Association 2987:805 806. WHO 2010 Costa Rica Human Pap illomavirus and Related Cancers, Fact Sheet 2010 S. WHO, I.I.C.o.H.a.C. Cancer. ACKNOWLEDGEMEN TS We would like to thank Nancy Romero Daza, David Himmelgreen, Heide Castaeda, Jenny Pena, Daniel Vargas, Kate Brelsford, and Gene Cowherd for the invaluable help and support they have given us. We would also like to thank the Novelty Castro for serving as our community advisor, the young women in the community who participated in our focus groups, the Clnica Santa Elena, the Colegio Tcnico Profesional Santa Elena, and the Monteverde Institute for making this research possible.

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APPENDIX A: Survey Cuestionario de Cncer de Cuello Uterino Tiene hijos? _____S _____No Si asisti al colegio, cul colegio asisti? ______________ _____No asist Estamos estudiando el conocimiento sobre el cncer de cuello uterino en San Luis. 1. Usted ha escuchado sobre el cncer de cuello de uterin o? _____ S Si s, Dnde? Marque las respuestas que aplican _____ No Escuela Trabajo Revistas o Libros Televisin Iglesia Clnica Familia Otra: Amigos Internet No quiere r esponder 2. Usted ha escuchado sobre el virus de papiloma humano? _____ S Si s, Dnde? Marque las respuestas que aplican _____ No Vaya a la pregunta 4 Escuela Trabajo Revistas o Libros Televisin Iglesia Clnica Familia Otra: Amigos Internet No quiere responder 3. C mo se puede contraer el papiloma?

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4. Queremos entender como se aprende sobre la salud sexual en Santa Elena y Monteverde. Voy a leer una lista de lugares y personas; por favor, indique si que cada articulo es una fuente de informacin para usted, responde con si o no. Si no quiere responder a la pregunta, no es un problema. Escuela Trabajo Revistas o Libros Televisin Iglesia Clnica Familia Otra: Amigos Internet No quiere responder 5. De stas, cuales fuentes de informacin le ayudan ms a entender su salud sexual? a. _______________________________ b. _______________________________ c. _______________________________ 6. Qu piensa que son las mejores formas para compartir informacin de salud sexual con mujeres jvenes? Por que? 7. En su experiencia, a cul edad ya no es necesario que las muchachas las acompae su mam cuando van al doctor? 8. En general, a qu edad comienzan las muchachas a tener relaciones sexuales en Santa Elena y Mont everde? Y que opina sobre esto?

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En esta seccin, lea las siguientes frases. Para cada frase, por favor responda sƒ‚ o no‚ de acuerdo a cada pregunta. S No El papiloma y cncer de cuello uterino son lo mismo. El papiloma tiene sntomas. El papiloma se puede contraer an cuando se usa el condn Solamente las mujeres pueden contraer el virus de papiloma humano. Solamente las personas promiscuas que tienen relaciones con ms de una pareja pueden contraer el virus de papiloma humano S asisti colegio, le educan sobre el virus de papiloma en su colegio. Siempre soy muy honesta con los doctores sobre mi salud sexual. Es posible curar el papiloma. El papiloma se puede contraer con contacto con la piel. Gracias por su s respuestas. En esta seccin, voy a preguntarles sobre su salud. 10. Alguna vez se ha hecho un Papanicola u? a. _____ S Pase a la prxima pregunta b. _____ No Pase a la seccin individual c. _____ Prefiero no responder 11. A qu edad se hizo su primer Papanicola u ? ______ 12. Dnde se hizo su examen de Papanicolau? a. ______ Clnica p blica b. ______ Cl nica privada c. _____ Feria de Salud d. _____ Otra ___________________________________ 13. Con que frecuencia tiene un Papanicolaou? a. _____ Cada ano b. _____ Cada dos a os c. _____ Otra __ _________________________________ Hay algo ms que le gustara compartir sobre este tema?

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17. Si usted tiene hijas, habla con ellas sobre su salud sexual? _____ Si _____ No Vaya a la pregunta 19 _____ Prefiero no responder 18. Si s cuando empez a hablar con su hija sobre la salud sexual? _____ Si _____ No _____ Prefiero no responder Sobre que hablaron? En esta seccin, por favor lea cada frase y marque la casilla correspondiente. 19 Una vez que mi hija cumpla 18 aos, su salud sex ual es su asunto y de nadie mas. Muy en desacuerdo En desacuerdo Neutro De acuerdo Muy de acuerdo 20 Es mi responsabilidad hablar con mi hija sobre su salud sexual. Muy en desacuerdo En desacuerdo Neutro De acuerdo Muy de acuerdo 21 Es l a responsabilidad de la clnica hablar con mi hija sobre su salud sexual. Muy en desacuerdo En desacuerdo Neutro De acuerdo Muy de acuerdo 22 Es la responsabilidad de el colegio hablar con mi hija sobre su salud sexual. Muy en desacuerdo En desa cuerdo Neutro De acuerdo Muy de acuerdo 23 S mucho sobre la salud sexual de mi hija. Muy en desacuerdo En desacuerdo Neutro De acuerdo Muy de acuerdo No aplica 24 Mi hija comparte mucho conmigo sobre su salud sexual. Muy en desacuerdo En desacuerdo Neutro De acuerdo Muy de acuerdo No aplica 25 Me siento cmoda hablando con mi hija sobre su salud sexual. Muy en desacuerdo En desacuerdo Neutro De acuerdo Muy de acuerdo No aplica 26 Me siento cmoda con que mi hija vi site la clnica por s sola. Muy en desacuerdo En desacuerdo Neutro De acuerdo Muy de acuerdo

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Muchsimas gracias por sus valiosas respuestas. Muchas gracias por sus respuestas. La ultima seccin es m s privada. Sin embargo, por favor recuerde que sus respuestas son totalmente opcionales y confidenciales. Este informacin es muy til para nuestro proyecto, pero reconocemos que tambin es informacin muy privada. 14. Ha tenido relaciones sexuales? a. _____ S b. _____ No c. _____ Prefiero no responder 15. A qu edad tuvo su primera experiencia sexual? a. _____ a os b. _____ Prefiero no responder 16. Ha tenido relaciones sexuales con: Marque las respuestas que aplican a. _____ Con condn b. _____ Sin condn c. _____ Pastillas anticonceptivas d. _____ DIU Dispositivo intrauterin o e. _____ Espermicida f. _____Otras________________ Hay algo ms que le gustara compartir sobre este tema? Esto concluye nuestro cuestionario. Muchsimas gracias por sus valiosas respuestas.

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APPENDIX B: Poster

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APPENDIX C: Informati on Sheet

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APPENDIX D : Game

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El Juego de VPH y Cncer de Cuello Uterino Incluye: Hoja de instrucciones Dos categoras 21 afirmaciones Cinta adhesiva Hoja con explicaciones Instrucciones: Este juego tiene la intencin de evaluar el conocimiento y para so bre el virus de papiloma humano y el cncer de cuello uterino. En este juego, la abreviatura VPH significa virus de papiloma humano. Hay 21 afirmaciones sobre VPH o el cncer de cuello uterino, algunos verdaderas, algunas falsas. Dependiendo de el nmer o de las estudiantes, se formaran grupos o se trabajara individualmente. Decidirn si la afirmacin es verdadera o falsa, y las separaran en la categora correspondiente. Despus de que las participantes hayan pegado las afirmaciones dentro de las cate goras, cuente los afirmaciones que han sido colocadas en la categora incorrecta. Dgale a los estudiantes cuantas afirmaciones han sido colocadas incorrectamente por ejemplo, Hay 3 afirmaciones falsas dentro de la categorƒa Verdadero‚. Pƒdale a las pa rticipantes adivinar cules son las incorrectas, discutirlas y corregirlas. AFIRMACIONES Falsas: 1. VPH y cncer de cuello uterino son lo mismo : VPH es un virus de transmisin sexual que causa el cncer de cuello uterino. El cncer de cuello uterino ocurre cuando clulas del cuello uterino crecen sin frenar. 2. VPH tiene sntomas : Normalmente, el cncer de cuello uterino no tiene sntomas. Algunos tipos de VPH causan verrugas genitales. En la mayora de los casos, el cuerpo se desembaraza de VPH natu ralmente. 3. Solamente las mujeres pueden contraer el VPH : Ambos hombres y mujeres pueden infectarse con VPH. 4. Es posible curar VPH : No hay una cura para el virus. Con ms exmenes y procedimientos se puede prevenir la formacin de cncer, destruyendo la s clulas anormales. 5. Si una persona est casada y tiene VPH, significa que su pareja le ha sido infiel : A veces el VPH est latente en el cuerpo por aos antes de llegar a ser detectable. 6. Hay un examen que puede detectar el VPH en los hombres : No ha y un examen que puede detectar el VPH en los hombres. Los hombres con VPH tienen el riesgo de verrugas genitales, cnceres de pene, ano y boca.

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7. Todos las personas que tienen VPH desarrollarn el cncer: Solo un pequeo porcentaje de gente desarrollar el cncer de cuello uterino. En el 2010, 403 mujeres en Costa Rica fueron diagnosticadas con el cncer de cuello uterino. Dos tipos de VPH causan el cncer, tipos 16 y 18. 8. Los hombres no necesitan preocuparse sobre el cncer: Los hombres podran infe ctarse con cnceres de pene, ano, boca, cabeza o cuello si se infectan con VPH. 9. Solo las mujeres ms viejas necesita preocuparse sobre el cncer de cuello uterino: En 2010, el cncer de cuello uterino fue el cncer ms comn en mujeres de 15 a 44 aos. 10. Es posible ver con mis ojos si mi pareja tiene VPH: Solo ciertos tipos de VPH causan verrugas genitales. Otros tipos no se pueden detectar. 11. Cuando una persona tiene VPH, lo tendr para siempre: La mayora de tipos de VPH se curan. Sin embargo, l os tipos que causan cncer viven en el cuerpo por ms tiempo. 12. Solo puedo contraer el VPH una vez: Es posible infectarse muchas veces y con tipos diferentes. 13. Pastillas anticonceptivas ayudan a proteger del VPH: En realidad, las pastillas anticonce ptivas aumentan el riesgo de cncer de cuello uterino en mujeres infectadas, pero este riesgo desaparece cuando se para de tomar pastillas. 14. Solo personas promiscuas pueden contraer el VPH: cualquiera puede infectarse con el VPH. Verdaderas 15. VPH s e puede contraer an cuando se usa un condn: Ya que el VPH se puede contraer a travs del contacto con la piel, es posible contraer el VPH an cuando se usa un condn. 16. VPH causa verrugas genitales: Dos tipos de VPH tipos 6 y 11 causan verrugas geni tales. 17. VPH se puede contraer a travs de contacto con la piel: el VPH se puede contraer con contacto con la piel, no solo a travs de los fluidos corporales. 18. VPH puede causar otros tipos de cncer: VPH puede causar cncer de pene, vagina, vulva, an o, boca, cabeza y cuello uterino. 19. Un examen de Papanicolau puede detectar si una mujer tiene VPH: Un Papanicolau busca clulas anormales en el cuello uterino, un sntoma del VPH. 20. El cncer de cuello uterino es el segundo tipo de cncer ms comn ti po en mujeres costarricenses. 21. La gente que fuma y tiene VPH tiene ms riesgo de desarrollar el cncer: El riesgo de cncer es ms elevado cuando una persona fuma. APPENDIX E : Survey Frequencies

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Age at time of the survey Frequency Percent Va lid Percent Cumulative Percent Valid 15 9 15.0 16.4 16.4 16 3 5.0 5.5 21.8 17 6 10.0 10.9 32.7 18 1 1.7 1.8 34.5 19 3 5.0 5.5 40.0 20 2 3.3 3.6 43.6 21 2 3.3 3.6 47.3 22 4 6.7 7.3 54.5 23 2 3.3 3.6 58.2 24 3 5.0 5.5 63.6 25 2 3.3 3.6 6 7.3 26 2 3.3 3.6 70.9 27 2 3.3 3.6 74.5 29 1 1.7 1.8 76.4 30 3 5.0 5.5 81.8 32 1 1.7 1.8 83.6 33 1 1.7 1.8 85.5 34 1 1.7 1.8 87.3 35 1 1.7 1.8 89.1 47 1 1.7 1.8 90.9 49 1 1.7 1.8 92.7 56 1 1.7 1.8 94.5 58 1 1.7 1.8 96.4 62 1 1.7 1 .8 98.2 65 1 1.7 1.8 100.0 Total 55 91.7 100.0 Missing System 5 8.3 Total 60 100.0

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Question 1 Have you heard of cervical cancer? €Usted ha escuchado sobre el cncer de cuello de uterino? Frequency Percent Valid Percent Cumulative Percent Valid 0 15 25.0 25.0 25.0 1 45 75.0 75.0 100.0 Total 60 100.0 100.0 Responses Percent of Cases N Percent Where have you heard of Cervical Cancer? School/Escuela 6 8.3% 30.0% Magazines/Revistas o Libros 10 13.9% 50.0% Church/Iglesia 2 2.8% 10.0% Family/Familia 5 6.9% 25.0% Friends/Amigos 7 9.7% 35.0% Internet 4 5.6% 20.0% Work/ Trabajo 4 5.6% 20.0% Television 12 16.7% 60.0% Clinica 16 22.2% 80.0% Other/Otra 6 8.3% 30.0% Total 72 100.0% 360.0%

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Question 2 Have yo u heard of HPV? €Usted ha escuchado sobre el VPH? Frequency Percent Valid Percent Cumulative Percent Valid 0 = no 6 10.0 10.0 10.0 1 = yes 54 90.0 90.0 100.0 Total 60 100.0 100.0 Responses Percent of Cases N Percent Where have you heard of H PV? School 4 10.5% 57.1% Magazines or books 4 10.5% 57.1% Church 1 2.6% 14.3% Family 2 5.3% 28.6% Friends 5 13.2% 71.4% Internet 4 10.5% 57.1% Work 2 5.3% 28.6% Television 6 15.8% 85.7% Clinic 4 10.5% 57.1% Other 6 15.8% 85.7% Total 38 1 00.0% 542.9% Question 3 How do you contract HPV? €C‚mo se puede contraer el papiloma? Frequency Percent Valid Percent Cumulative Percent Valid 99 12 20.0 20.0 20.0 By Contact 1 1.7 1.7 21.7 Coital relations 1 1.7 1.7 23.3 Condoms 1 1.7 1.7 2 5.0 Don't know 4 6.7 6.7 31.7 Having sex at an early age, with different partner 1 1.7 1.7 33.3

PAGE 27

Not sure, women 1 1.7 1.7 35.0 Relations outside of a pair 1 1.7 1.7 36.7 Sexual contact 4 6.7 6.7 43.3 Sexual relations 18 30.0 30.0 73.3 Sexual Relations 1 1.7 1.7 75.0 Sexual relations without protecion 1 1.7 1.7 76.7 Sexual relations; sangre 1 1.7 1.7 78.3 Sexual transmission 11 18.3 18.3 96.7 Unprotected sex 2 3.3 3.3 100.0 Total 60 100.0 100.0 Question 4 Responses Percent of Case s N Percent Best place to impart Sexual education School/Escuela 38 14.3% 66.7% Magazines/Revistas o Libros 33 12.5% 57.9% Church/Iglesia 6 2.3% 10.5% Family/Familia 37 14.0% 64.9% Friends/Amigos 29 10.9% 50.9% Internet 29 10.9% 50.9% Traba jo 6 2.3% 10.5% Television 40 15.1% 70.2% Clinic/ Clinica 47 17.7% 82.5% Total 265 100.0% 464.9% Question 5 1 Which three sources of information were most helpful in your unde rstanding of sexual health?; 1 €De ƒstas, cuales fuentes de informaci‚n le ayudan ms a entender su salud sexual? Frequency Percent Valid Percent Cumulative Percent Valid All 1 1.7 1.7 1.7 Books 3 5.0 5.2 6.9 Clinic 21 35.0 36.2 43.1 Family 7 11.7 12.1 55.2

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Friends 5 8.3 8.6 63.8 Internet 2 3.3 3.4 67.2 Magazines 5 8.3 8.6 75.9 Magazines/Books 1 1.7 1.7 77.6 School 7 11.7 12.1 89.7 TV 6 10.0 10.3 100.0 Total 58 96.7 100.0 Missing 99 2 3.3 Total 60 100.0 2Which three sources of information were most helpful in your understanding of sexual health?; 2€De ƒstas, cuales fuentes de informaci‚n le ayudan ms a entender su salud sexual? Frequency Percent Valid Percent Cumulative Percent Valid 99 12 20.0 20.0 20.0 All 1 1.7 1.7 21.7 Books 1 1.7 1.7 23.3 Centros Medicos 1 1.7 1.7 25.0 Clinic 9 15.0 15.0 40.0 Family 11 18.3 18.3 58.3 Friends 3 5.0 5.0 63.3 Internet 13 21.7 21.7 85.0 School 5 8.3 8.3 93.3 Television 1 1.7 1.7 95.0 TV 3 5.0 5.0 100.0 Total 60 100.0 100.0 3 Which three sources of information we re most helpful in your understanding of sexual health?; 3 €De ƒstas, cuales fuentes de informaci‚n le ayudan ms a entender su salud sexual? Frequency Percent Valid Percent Cumulative Percent Valid 99 21 35.0 35.0 35.0 All 1 1.7 1.7 36.7 Books 1 1.7 1.7 38.3 Clinic 6 10.0 10.0 48.3

PAGE 29

Clinics 1 1.7 1.7 50.0 Family 4 6.7 6.7 56.7 Friends 3 5.0 5.0 61.7 Internet 2 3.3 3.3 65.0 Interview 1 1.7 1.7 66.7 Magazines 2 3.3 3.3 70.0 Magazines/Books 4 6.7 6.7 76.7 School 6 10.0 10.0 86.7 Specialists in sex 1 1.7 1.7 88.3 Television 1 1.7 1.7 90.0 TV 5 8.3 8.3 98.3 Work 1 1.7 1.7 100.0 Total 60 100.0 100.0 Question 7 In your experience at what age is it not necessary for mothers to accompany young women to the clinic €En su expe riencia, a cul edad ya no es necesario que las muchachas las acompa„e su mam cuando van al doctor? Frequency Percent Valid Percent Cumulative Percent Valid 99 2 3.3 3.3 3.3 11 1 1.7 1.7 5.0 12 2 3.3 3.3 8.3 13 14 1 1.7 1.7 10.0 14 1 1.7 1.7 1 1.7 15 6 10.0 10.0 21.7 15,18 1 1.7 1.7 23.3 16 2 3.3 3.3 26.7 16 17 1 1.7 1.7 28.3 17 4 6.7 6.7 35.0 18 19 31.7 31.7 66.7 18 20 1 1.7 1.7 68.3 20 4 6.7 6.7 75.0 27 1 1.7 1.7 76.7 After having sex 1 1.7 1.7 78.3

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always 1 1.7 1.7 80.0 Always 2 3.3 3.3 83.3 Cuando esta viejita 1 1.7 1.7 85.0 Depends 3 5.0 5.0 90.0 Not specific 1 1.7 1.7 91.7 They need trust 2 3.3 3.3 95.0 When one needs too 2 3.3 3.3 98.3 when they are young 1 1.7 1.7 100.0 Total 60 100.0 100.0 Questio n 8 In general, at what age do young women begin sexual relations? €En general, a quƒ edad comienzan las muchachas a tener relaciones sexuales? Frequency Percent Valid Percent Cumulative Percent Valid 99 6 10.0 10.0 10.0 11 12 1 1.7 1.7 11.7 12 4 6 .7 6.7 18.3 12 13 6 10.0 10.0 28.3 13 10 16.7 16.7 45.0 13 14 2 3.3 3.3 48.3 13 15 3 5.0 5.0 53.3 14 8 13.3 13.3 66.7 14 15 2 3.3 3.3 70.0 15 11 18.3 18.3 88.3 15 16 2 3.3 3.3 91.7 15 17 1 1.7 1.7 93.3 15 20 1 1.7 1.7 95.0 16 1 1.7 1. 7 96.7 18 1 1.7 1.7 98.3 Depends 1 1.7 1.7 100.0 Total 60 100.0 100.0

PAGE 31

Phrase Questions Question 9 Have you had a pap? €Alguna vez se ha hecho un Papanicolau? Frequency Percent Valid Percent Cumulative Percent Valid 0 = no 25 41.7 43.1 43.1 1 = yes 33 55.0 56.9 100.0 Total 58 96.7 100.0 Missing 99 2 3.3 Question 10 Age at first pap; €A quƒ edad se hizo su primer Papanicolau? Frequency Percent Valid Percent Cumulative Percent Valid 15 2 3.3 6.5 6.5 17 4 6.7 12.9 19.4

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18 3 5.0 9.7 29.0 19 3 5.0 9.7 38.7 20 8 13.3 25.8 64.5 21 2 3.3 6.5 71.0 22 1 1.7 3.2 74.2 23 4 6.7 12.9 87.1 24 1 1.7 3.2 90.3 25 2 3.3 6.5 96.8 30 1 1.7 3.2 100.0 Total 31 51.7 100.0 Missing 99 29 48.3 Total 60 100.0 Question 11 Where have you gotten a pap smear? €D‚nde se hizo su examen de Papanicolau? Frequency Percent Valid Percent Cumulative Percent Valid 0 public 19 31.7 57.6 57.6 1 private 14 23.3 42.4 100.0 Total 33 55.0 100.0 Missing 99 27 45.0 Total 60 100. 0 Question 12 How frequently do you get a pap? €Con que frecuencia tiene un Papanicolaou? Frequency Percent Valid Percent Cumulative Percent Valid .0 every year 24 40.0 68.6 68.6 1.0 every 2 years 7 11.7 20.0 88.6 2.0 otra 4 6.7 11.4 100.0 T otal 35 58.3 100.0 Missing 99.0 25 41.7 Total 60 100.0

PAGE 33

Question 13 Have you had sexual relations €Ha tenido relaciones sexuales? Frequency Percent Valid Percent Cumulative Percent Valid 0 15 25.0 30.0 30.0 1 35 58.3 70.0 100.0 Total 50 83 .3 100.0 Missing 99 7 11.7 97 3 5.0 Total 10 16.7 Total 60 100.0 Question 14 At what age was your first sexual experience €A quƒ edad tuvo su primera experiencia sexual? Frequency Percent Valid Percent Cumulative Percent Valid 13 1 1 .7 3.3 3.3 14 1 1.7 3.3 6.7 15 3 5.0 10.0 16.7 16 5 8.3 16.7 33.3 17 8 13.3 26.7 60.0 18 4 6.7 13.3 73.3 20 2 3.3 6.7 80.0 21 1 1.7 3.3 83.3 22 3 5.0 10.0 93.3 24 1 1.7 3.3 96.7 25 1 1.7 3.3 100.0 Total 30 50.0 100.0 Missing 99 24 40.0 97 6 10.0 Total 30 50.0 Total 60 100.0

PAGE 34

Question 15 with condom; con cond€n without condom; sin cond€n birth control pills; Pastillas anticonceptivas with a DUI; con DIU Dispositivo intrauterino N Valid 37 37 37 34 Missing 23 23 23 26 Mean .84 .49 .68 .09 Median 1.00 .00 1.00 .00 Mode 1 0 1 0 with spermicide con: Espermicida with other; con Otras N Valid 34 60 Missing 26 0 Mean .00 Median .00 Mode 0 Question 16 If you have daughters, did you talk to them ab out their sexual health; Si usted tiene hijas, habla con ellas sobre su salud sexual? Frequency Percent Valid Percent Cumulative Percent Valid .00 = no 14 23.3 58.3 58.3 1.00 = yes 10 16.7 41.7 100.0 Total 24 40.0 100.0 Missing 99.00 35 58.3 97.00 1 1.7 Total 36 60.0 Total 60 100.0

PAGE 35

Question 17 If yes, at what age; Si si, cuando empezo a hablar con su hija sobre la salud sexual? Frequency Percent Valid Percent Cumulative Percent Valid .00 = no 4 6.7 30.8 30.8 1.00 = y es 9 15.0 69.2 100.0 Total 13 21.7 100.0 Missing 99.00 46 76.7 97.00 1 1.7 Total 47 78.3 Total 60 100.0 Question 18 Una vez que mi hija cumpla 18 anos, su salud sexual es su asunto y nadie mas Frequency Percent Valid Percent Cumulati ve Percent Valid 1.00 Muy en desacuerdo 10 16.7 27.0 27.0 2.00 En desacuerdo 13 21.7 35.1 62.2 3.00 Neutro 5 8.3 13.5 75.7 4.00 De acuerdo 7 11.7 18.9 94.6 5.00 Muy de acuerdo 2 3.3 5.4 100.0 Total 37 61.7 100.0 Missing 99.00 23 38.3 Total 60 100.0 Question 19 Es mi responsabilidad hablar con mi hija sobre su salud sexual Frequency Percent Valid Percent Cumulative Percent Valid 1.00 Muy en desacuerdo 1 1.7 2.7 2.7 3.00 Neutro 1 1.7 2.7 5.4 4.00 De acuerdo 8 13.3 21.6 27.0 5.00 Muy de acuerdo 27 45.0 73.0 100.0 Total 37 61.7 100.0 Missing 99.00 23 38.3 Total 60 100.0

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Question 20 Es la responsabilidad de la clinica hablar con mi hija sobre su salud sexual Frequency Percent Valid Percent Cumulative Percent Valid 1.00 Muy en desacuerdo 1 1.7 2.7 2.7 2.00 En desacuerdo 7 11.7 18.9 21.6 3.00 Neutro 11 18.3 29.7 51.4 4.00 De acuerdo 13 21.7 35.1 86.5 5.00 Muy de acuerdo 5 8.3 13.5 100.0 Total 37 61.7 100.0 Missing 99.00 23 38.3 Total 60 100.0 Question 21 Es la responsabilidad de el colegio hablar con mi hija sobre su salud sexual Frequency Percent Valid Percent Cumulative Percent Valid 1.00 Muy en desacuerdo 1 1.7 2.7 2.7 2.00 En desacuerdo 7 11.7 18.9 21.6 3.00 Neutro 6 10.0 16.2 37.8 4.00 De acuerdo 18 30.0 48.6 86.5 5.00 Muy de acuerdo 5 8.3 13.5 100.0 Total 37 61.7 100.0 Missing 99.00 23 38.3 Total 60 100.0 Question 22 Se mucho sobre la salud sexual de mi hija Frequency Percent Valid Percent Cumulative Percent Valid 1.00 Mu y en desacuerdo 2 3.3 8.0 8.0 2.00 En desacuerdo 3 5.0 12.0 20.0 3.00 Neutro 8 13.3 32.0 52.0 4.00 En acuerdo 8 13.3 32.0 84.0 5.00 Muy en de acuerdo 2 3.3 8.0 92.0 6.00 no aplica 2 3.3 8.0 100.0 Total 25 41.7 100.0

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Missing 99.00 35 58.3 Question 23 Mi hija comparte mucho conmigo sobre su salud sexual Frequency Percent Valid Percent Cumulative Percent Valid 9.00 1 1.7 4.2 4.2 1.00 Muy en desacuerdo 1 1.7 4.2 8.3 2.00 En desacuerdo 4 6.7 16.7 25.0 3.00 Neutro 7 11.7 29.2 54.2 4 .00 En acuerdo 6 10.0 25.0 79.2 5.00 Muy en desacuerdo 3 5.0 12.5 91.7 6.00 no aplica 2 3.3 8.3 100.0 Total 24 40.0 100.0 Missing 99.00 36 60.0 Total 60 100.0 Question 24 Me siento comoda hablando con mi hija sobre su salud sexual Freque ncy Percent Valid Percent Cumulative Percent Valid 1.00 Muy en desacuerdo 2 3.3 8.7 8.7 2.00 En desacuerdo 2 3.3 8.7 17.4 3.00 Neutro 7 11.7 30.4 47.8 4.00 En acuerdo 7 11.7 30.4 78.3 5.00 Muy en desacuerdo 3 5.0 13.0 91.3 6.00 no aplica 2 3.3 8 .7 100.0 Total 23 38.3 100.0 Missing 99.00 37 61.7 Total 60 100.0 Question 25 Me siento comoda con que mi hija visite la clinica por si sola Frequency Percent Valid Percent Cumulative Percent Valid 1.00 Muy en desacuerdo 4 6.7 14.8 14.8 2. 00 En desacuerdo 6 10.0 22.2 37.0

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3.00 Neutro 9 15.0 33.3 70.4 4.00 En acuerdo 7 11.7 25.9 96.3 5.00 Muy en desacuerdo 1 1.7 3.7 100.0 Total 27 45.0 100.0 Missing 99.00 33 55.0 Total 60 100.0


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