INTRODUCTION

Adherence to vaccination against Human Papillomavirus (HPV) among adolescents is essential for controlling cervical cancer (CC), the most common malignancy in women in underdeveloped countries ¹ . In Brazil, the implementation of the quadrivalent anti-HPV vaccine by the Unified Health System (SUS) is recent, made available in 2014 for girls between 11 and 13 years old with a vaccination schedule of three doses at 0, 6 and 60 months ² . In 2017, the Ministry of Health (MS) began implementing vaccination against HPV also for boys aged 12 to 13 years old, as well as extending the age range for vaccination of girls from nine to 14 years old ³ .

Currently, vaccination data for the year 2014 indicated that almost half of Brazilian municipalities had low vaccination coverage against HPV ⁴ . Although coverage for the first dose of the vaccine exceeded 70% in 2015, the figures did not reach 60% for the second dose ⁵ . According to the Ministry of Health, sporadic cases of psychogenic reactions after vaccination that were widely reported in the media, especially on online social networks (OSN), caused both parents and adolescents to fear the safety of the vaccine, explaining the reduction in vaccination coverage for the second dose ⁶ .

Many studies have identified factors that contribute to low adherence to HPV vaccination. Lack of knowledge about the vaccine, lack of awareness, and lack of recommendations from providers represent the main barriers to HPV vaccination ^7-10 . In this scenario, the development of mobilizing strategies based on health education can emerge as a supporting factor in efforts to reduce barriers to adherence to HPV vaccination campaigns.

Due to technological and cultural transformations, the Internet has currently become a significant tool for obtaining knowledge, information, and training for users. In fact, some institutions and public bodies already use RSO to disseminate health information and to interact with the population, publicizing actions, campaigns and programs ^11,12 . In addition, numerous studies have indicated RSO as an important tool for the dissemination of healthy lifestyle habits ^13-17 , suggesting their use in health-promoting strategies.

Thus, identifying adolescents’ perceptions regarding the relationship between HPV and CC, identifying the means by which they received information on this topic, and describing their patterns of Internet and RSO use can foster pertinent discussions regarding the feasibility of using the Internet to strengthen HPV infection control actions among adolescents. Thus, the aim of this study was to analyze the pattern of Internet and other information and communication technologies (ICT) use by 9th grade girls, with the intention of using them to design health education interventions aimed at strengthening HPV transmission control actions.

METHODOLOGY

Type of study

A descriptive, cross-sectional study with a quantitative approach was conducted in nine of the 28 state schools in the city of Maringá.

Study location

The study was conducted in public schools in the state network of Maringá. At the time of the study, there were 28 schools in the city, of which nine were selected based on their scores on the Prova Brasil. This test is carried out by the Ministry of Education and aims to evaluate schools through specific questionnaires for students. Schools were divided into levels 2, 3 and 4, according to the grades obtained in the subjects of Portuguese Language and Mathematics.

Sampling

Stratified random cluster sampling was used, since the adolescents were enrolled in various schools in the state network. The total number of students enrolled in the 9th grade in 2016 was 2,971, and since it was not possible to identify the exact number of girls enrolled, since the available data were related to the total number of students, a statistical average was calculated from the total number of students in the 9th grade. The sample was calculated considering the level of significance and the maximum error allowed between the estimate and the real value of the parameter. Thus, it was verified that the questionnaire needed to be applied to at least 226 adolescents in order to estimate the factors of interest. Thus, it was also estimated that the number of participating schools should be nine, to understand the total number of students needed. A total of 300 Free and Informed Consent Forms (FICs) were handed out, however 70 girls did not bring their FICs on the scheduled date for collection, and the questionnaire was applied to 230 adolescents.

Data collection

Data collection was carried out in three phases, between August and October 2016. In the first phase, the first contact was made with the pedagogical coordinators of the schools to explain the research and request authorization. In the second phase, the adolescents were contacted to explain the research and schedule the collection date. They were also given the informed consent form to bring on the scheduled collection date, which was no more than 10 days away. The third phase consisted of the application of the questionnaire, in which the adolescents who had the informed consent form signed by their guardian were sent to another room to answer it.

Data analysis

The results were analyzed through descriptive analysis to obtain frequency tables in order to outline the sociodemographic profile, knowledge profile about HPV, and profile of access to information and communication technologies by the adolescents, with the help of the statistical package R (R Development Core Team).

Ethical aspects

The study was approved by the Human Research Ethics Committee of the Cesumar University Center under number 37086014.3.0000.5539 and authorized by the Maringá State Education Center.

RESULTS

Population characterization

The distribution of data regarding the sociodemographic profile of the adolescents and their parents is shown in Table 1. It was observed that almost half of the adolescents who participated in the study (47%) were 14 years old and only 6% were over 16 years old. Approximately one third of them reported having a family income of more than two minimum wages, while 41% did not know what their family income was. 26% of the students indicated that they did not know their father’s level of education and a total of 33% responded that their father had completed or incomplete elementary school. Regarding the mother, 15% of them did not know what her education level was, while 31% indicated that their mother had completed or incomplete elementary education and another 31% had completed or incomplete high school education. It was found that half of the students (50%) belong to the Catholic religion and 41% to the Evangelical religion.

Perception of HPV transmission and its relationship with CC

Table 2 presents data regarding the perception of adolescents about HPV transmission and its relationship with cancer. It was observed that the vast majority of girls (85%) responded that HPV is a virus. 96% of them indicated that HPV is transmitted during sexual intercourse, while 57% and 48% said that those who can catch HPV are people who have sexual intercourse without a condom and only women, respectively. When asked about the diseases that HPV can cause, only 5% of the adolescents indicated liver cancer and 29% penile cancer, while 68% and 43% responded that HPV can cause ovarian cancer and genital warts, respectively. Furthermore, 88% of the girls indicated that HPV can cause CC and only 20% responded that throat and mouth cancer. 94% of girls indicated that HPV can turn into cancer and 97% believe there is a link between HPV and sexual intercourse.

Description of sources of information about HPV and CC

Only 1% of the survey participants stated that they had not heard about HPV before. The sources most cited by those who had heard about it were the health center and TV, cited by 74% and 60% of all girls, respectively. When asked if they had heard about the importance of undergoing preventive exams, 9% responded negatively, and the sources most cited were the health center and TV, cited by 68% and 43% of the students, respectively.

Description of the profile of use of Information and Communication Technologies (ICT)

Tables 4 and 5 show the distribution of data regarding the characterization of the digital behavior profile of adolescents. It was noted that just over half of the interviewees (55%) have a personal computer, 97% do not need help to use the computer and 48% of the interviewees have been using computers for more than five years.

It was also observed that more than 90% of the adolescents access the Internet most of the time through paid Wi-Fi. The cell phone is the device most used by 94% of the interviewees to access the Internet and 46% of them do not have a fixed time in which they use the Internet per day.

A total of 82% of the girls have e-mail, and more than half (53%) almost never access their e-mail.

97% of the interviewees have cell phones and most of them have been using them for more than five years (42%), with the most common brand of device being Samsung (47%). A total of 94% of the girls participating in the survey have a cell phone with Internet access, and they use the device most frequently to access the Internet and make calls (96% and 58% of them, respectively).

Only one of the 230 adolescents indicated that she does not have social networks. On the other hand, more than 90% of them use Facebook, Whatsapp and/or YouTube . Furthermore, 97% and 83% of the girls indicated that they use the Internet to access social networks and/or conduct research, respectively. Almost half of the interviewees (48%) use video messenger as a resource to communicate via video over the Internet. Finally, the most common technological equipment, in addition to those already mentioned, that the interviewees have is the pen drive (73%), followed by the digital camera (47%).

DISCUSSION

The transmission of HPV and its relationship with CC infection are extremely relevant factors to be discussed in a sexually active population, especially in younger populations, since they have a high prevalence rate of HPV infection ^18,19 . However, the perception of the adolescent population about HPV and its relationship with CC is still insufficient ^20,21 , and is limited almost exclusively to issues related to the transmission and development of diseases associated with HPV ²² . This fact is demonstrated in our study, in which the majority of the adolescents surveyed knew what HPV was and its relationship with CC, however 48% of them related the transmission of HPV only to the female sex.

Unfortunately, adherence to CC prevention campaigns, especially HPV vaccination, by younger populations is still a challenge, since the decision to take the vaccine requires a certain level of information from this population and their families. Through our study, it was possible to understand the quality of information about HPV and its relationship with CC among the adolescent population, and to verify by what means this population obtained this information. It was also possible to identify the profile of ICT use by the adolescents surveyed. And given the results presented, there was evidence that ICT is extremely used by this population in their daily lives, and this fact reinforced the idea of ​​using ICT in the development of strategies that provide accessible and reliable information about HPV transmission and CC prevention.

The average age of the adolescents participating in our study was 14 years. This corroborates our proposal to investigate the perception of CC control actions in the target population of HPV vaccination campaigns ²³ . Although approximately half of the adolescents did not know their parents’ family income and level of education, those who responded to this question indicated that their income was greater than two minimum wages and that their level of education was elementary school. These data suggest that the population investigated in this study shares sociodemographic similarities with the majority of families in the country that depend almost exclusively on the SUS for health care ²⁴ .

Since information and knowledge play an important role in adherence to the HPV vaccine ²⁵ , the development of strategies that use tools focused on the young population is of fundamental importance for promoting the health of this population. The Internet is accessed by more than 100 million Brazilians, with the cell phone being the most used device for individual Internet access ²⁶ , which is in line with our results, which indicated that slightly more than half of the adolescents who participated in this study have a computer, however, almost all have a cell phone with Internet access. In turn, of the 230 adolescents surveyed, only one indicated that she did not use social networks such as Facebook and WhatsApp , which demonstrated the potential of RSO as a vehicle for information to this population, which, with a vast audience and countless possibilities of use, can be used in different ways, with a focus on promoting the population’s sexual health ²⁷ .

One of the most powerful communication tools of the 21st century is social media, as it includes web tools and applicationsdesigned to facilitate online interaction and instant sharing of information among users ²⁸ . Their function is diverse: they help people communicate, discuss topics of interest and share their common interests, as well as providing freedom to express their emotions and opinions. However, even though there is a need for new strategies to reach the adolescent population, the origin of this information and its degree of quality and veracity must be considered. The evaluation of existing videos on YouTube about HPV identified that the majority have been in favor of the HPV vaccine, however videos that present negative content have a higher number of views ²⁹ .

The adolescents surveyed in our study responded that they obtained information about HPV and the HPV vaccine through television and health clinics. These information vehicles are undoubtedly of great value to the community. However, the potential for using ICT, especially among the adolescent population, increases every year, and has already shown to be beneficial for increasing knowledge about STDs and reducing risk behavior ²⁷ . The fact that the Internet has been widely used for health research ^29,30 and that social networks are being used by patients to share personal information about their diseases ^29,31 reinforces the hypothesis of using ICT as a tool to be used in health empowerment with adolescents.

Given the fact that levels of awareness and health education increase the immunization rates of a population ³² and thus, every effort made to improve health information contributes to meeting the needs of the population ³³ , our study corroborates relevant information about the perception of adolescents regarding the topic of HPV and CC and how they can be mobilized by ICT to materialize their knowledge on the topic. This information may indicate possible tools for creating new strategies that focus on the adolescent population. It is therefore essential to create policies that promote accurate information for the adolescent population and their families. Furthermore, health professionals should be aware that their influence and information motivate individuals in making decisions about their health.

CONCLUSION

We concluded that the vast majority of adolescents know what HPV is, how it is transmitted, and its health consequences, including CC. It was also possible to demonstrate that the means that provided the most information about the virus to the target population were the Health Centers, where the young women also heard about the importance of preventive exams. Regarding the use of ICT, the majority have access to the Internet and do so through cell phones, where they use the device mainly to access RSO, among which the most used are Facebook, Whatsapp , and YouTube .

Thus, we understand that these technological means mentioned have the potential to offer health literacy, especially among young people and adolescents, since this age group widely uses digital media and can become protagonists in raising awareness about HPV, CC, and its prevention, also due to the fact that the primary prevention of this disease is vaccination.

ACKNOWLEDGMENTS

The data in this article were part of the Universal Project of the National Council for Scientific and Technological Development (CNPq), coordinated by the author Marcelo Picinin Bernuci – Project Number: 455495/2014-9.