Predictors of HPV Knowledge and HPV Vaccine Awareness Among Women in Panama City, Panama

Date01 March 2019
AuthorLourdes Baezconde‐Garbanati,Lisa Gantz,Fiorella Gonzales,Joyee S. Chatterjee,Sheila Murphy,Lourdes Alguero,Morgan Hess‐Holtz,Lauren B. Frank,Paula Amezola de Herrera,Arlene Calvo,Meghan Moran
Published date01 March 2019
Predictors of HPV Knowledge and HPV Vaccine
Awareness Among Women in Panama City, Panama
Lisa Gantz , Arlene Calvo, Morgan Hess-Holtz, Fiorella Gonzales,
Lourdes Alguero, Sheila Murphy, Meghan Moran, Lauren B. Frank,
Joyee S. Chatterjee, Paula Amezola de Herrera,
and Lourdes Baezconde-Garbanati
In 2008, Panama became the f‌irst country in Latin America to offer the Human Papilloma Virus
(HPV) vaccine at no cost to 10-year-old girls as part of its National Immunization Program.
Vaccine completion rates remain suboptimal, and knowledge is limited regarding public perceptions
of the HPV vaccine in Panama. A cross-sectional survey of 333 Panamanian women aged 18–65
was conducted in Panama City, Panama. Although 93 percent of respondents had heard of HPV,
only 59.8 percent had heard of the HPV vaccine. Acceptability of HPV vaccination of daughters
was high (95 percent). In multivariate analyses, HPV vaccine awareness was associated with age
and education, but not with income, Internet use as preferred source of health information,
indigenous race, or marital status. Additionally, after controlling for age, education, income, race,
and Internet use, women who completed a pap test in the past 36 months were 3.12 times more
likely to have heard of the HPV vaccine when compared to those who had not (95%CI 1.04–9.34).
Future efforts to educate Panamanian women about the HPV vaccine should include special
attention to vulnerable populations, including those of younger age and limited education.
KEY WORDS: HPV vaccine, HPV, Panama
Globally, cervical cancer kills over 250,000 women each year, with over 85
percent of these deaths occurring in developing countries (Forman et al., 2012).
Cervical cancer is caused by infection with the human papilloma virus (HPV),
which is also responsible for cancers of the vulva, vagina, anus, penis, and
oropharynx. Cancers caused by HPV account for more than half of infection-
attributed cancers in women worldwide (Plummer et al., 2016). The HPV vaccine
brings new hope to resource-limited settings, with the potential to prevent
infections with HPV strains responsible for over 70 percent of cervical cancers
globally (Mu~
noz et al., 2008; Schiffman, Castle, Jeronimo, Rodriguez, &
World Medical & Health Policy, Vol. 11, No. 1, 2019
doi: 10.1002/wmh3.293
#2019 Policy Studies Organization
Wacholder, 2007). In the Latin American and Caribbean (LAC) region, an
estimated 1.1 million cases of invasive cervical cancer could be prevented within
this region with 70 percent coverage of the HPV vaccine over a 10-year period
(Goldie et al., 2008).
Despite the immense potential of the HPV vaccine to prevent cancer-related
morbidity and mortality, in many settings, initiation and completion of the vaccine
series has been lower than expected, including in the United States (Holman et al.,
2014; Walker et al., 2017). When evaluating the success of a vaccine campaign,
numerous factors must be considered. These factors include practical barriers, such
as vaccine cost and access to health care, but should also include public
perceptions, including vaccine acceptability, endorsement from health-care pro-
viders, knowledge attitudes, and beliefs related to the vaccine. Studies have shown
that even when practical barriers are eliminated, misinformation, stigma, lack of
knowledge, and safety concerns can impede the success of a vaccine program
(Larson et al., 2016; Ogilvie et al., 2010), highlighting the importance of understand-
ing public perceptions of the HPV vaccine to inform ongoing messaging via mass
media and awareness campaigns to educate the public and dispel rumors. This is
especially important for the HPV vaccine, which has been particularly controversial
due to the sexually transmitted nature of the virus and the recommended age of
administration (in adolescents, prior to sexual debut) (Holman et al., 2014, Kane,
Serrano, de Sanjose, & Wittet, 2012). Sexually transmitted infection immunization
programs may face unique stigma based on sexual morality or religion, and are
often met with resistance from those who fear that these programs may condone or
encourage premarital sex (Zimet, Mays, & Fortenberry, 2000).
Cervical Cancer and HPV in Panama
Panama is an upper-middle-income country located in Central America with
a population of approximately 4 million people (Fantom & Serajuddin, 2016).
Cervical cancer rates have historically been extremely high in Panama, where
epidemiologic case-control studies of women in the 1980s f‌irst identif‌ied the
causal link between HPV and cervical cancer (Herrero et al., 1990). Although
Panama offers universal access to free health care, cervical cancer, a disease that
is preventable with timely screening and treatment of precancerous lesions,
continues to rank second in both incidence (25.3 per 100,000) and mortality (7.4
per 100,000) among female cancers (MINSA, 2013). The HPV vaccine represents a
tremendous opportunity for Panama to reduce rates of cervical cancer, as pap
coverage rate estimates are as low as 14.1 percent (MINSA, 2010). Effective
screening programs can be costly and diff‌icult to implement even when there is
universal access to health care, as there are many practical barriers to the patients
themselves (such as transportation, long wait times in clinic), as well as systemic
barriers that pose challenges to government health agencies (such as coordinating
follow-up appointments, maintaining quality control of specimen handling, and
training a suff‌icient number of pathologists for accurate interpretation) (Mu ~
et al., 2008). Despite the high prevalence of both HPV and cervical cancer among
96 World Medical & Health Policy, 11:1

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