2012. Vol.3, Special Issue, 1138-1149
Published Online October 2012 in SciRes (http://www.SciRP.org/journal/ce) http://dx.doi.org/10.4236/ce.2012.326170
Copyright © 2012 SciRes.
An Experience in the Prevention of HPV by and for Adolescents:
A Community Randomized Trial of the Effect of Peer Health
Education on Primary Prevention in a 1-Year Follow Up*
Elisa Langiano1, Maria Ferrara1, Maria Gabriella Calenda2, Luciano Martufi3,
Elisabetta De Vito1
1Department of Humanities, Social and Health Sciences, Campus Folcara, University of Cassino and Southern
Lazio, Sant’ Angelo St, Italy
2LHA—Local Health Authority Children’s Clinic, Frosinone, Italy
3LHA—Coordination Centre of Screening Programmes, Frosinone, Italy
Email: email@example.com, firstname.lastname@example.org, email@example.com,
Received August 30th, 2012; revised September 28th, 2012; accepted October 14th, 2012
Background: HPV is the most common sexually transmitted disease in many regions of the world. 15%
was found in women aged 15 - 19 years but the highest incidence of infection from HPV can be found in
sexually active adolescents: between 50% and 80% of them catch the infection within two to three years
from their first sexual relationship. Methods: A community randomized trial regarding HPV infection
and HPV vaccination, and sexual health was carried out, in a sample of secondary school students. Peer
edu- cation intervention was carried out and 2 follows-up were carried out after the educative intervention
to evaluate the effective outcomes in a 1-year follow up of the effect of peer health education on primary
prevention knowledge, attitude and behaviour towards HPV. Results: The sample of 900 students, with
age of 16.6 ± 1.4 ds, 34.4% of which have sexual relationships. 64.6% of students in the experimental
group said that they were aware of HPV, 83.4% were aware of how it is transmitted and 71.1% knew
HPV vaccination, 54.7% perceived the level of danger with significant gender-related differences the
percentages increased at T1. At T0, 14.1% of females were vaccinated: T1 they were 17.5% and 19.2% at
T2. The main factors associated with the students’ propensity to vaccination were: having at least one sis-
ter; being in favor of vaccinations in general; knowing that the vaccine is aimed at preventing cervical
cancer; and being aware that they could be infected by HPV. Conclusion: The study carried out high-
lights important differences between the experimental group and the control group in terms of knowledge
but, most importantly, in terms of behaviour and it proves how the application of new educational meth-
ods based on the involvement of youngsters right from the initial stages of the project can help them to
change their behaviour and maintain it in time.
Keywords: HPV; Prevention; Adolescents; Peer Education; Evaluation Efficacy
Infection from HPV is the most common sexually transmit-
ted disease in many regions of the world. The persistent infec-
tion with one of the tumorogenic Human Papilloma Viruses
(HPV) is recognized as the necessary cause of almost all cases
of Cercical Cancer Uteri (CCU). Furthermore, it is also associ-
ated with at least half of all of the other forms of cancer of the
lower genital tract in women and in men and a lower percent-
age, from 2 to 10%, of the so-called head-neck tumours (Vac-
carella, 2010; Franco & Harper, 2005; IARC, 2007; Roden,
Morris Ling, & Wu, 2004; Schiffman, Castle, Jeronimo, Rod-
riguez, & Wacholder, 2007; Syrjänen, 2005). Controls of infec-
tion from HPV, carried out in four continents by the Interna-
tional Agency for Research on Cancer (Lyon), have proved that
the majority of the infection varies substantially from one
population to another and ranges from 2% to 50% in women
aged between 15 and 64. A higher percentage by 15% was
found in women aged between 15 and 19 years of age but the
highest percentage and incidence of infection from HPV can be
found in sexually active adolescents, in fact between 50% and
80% of them catch the infection within two to three years from
their first sexual relationship (Baseman & Koutsky, 2005;
Louvanto, Rintala, Syrjänen, Grénman, & Syrjänen, 2011; Pi-
ana, Sotgiu, Castiglia et al., 2011; Pieralli, Fallani, Lozza et al.,
2011; Vaccarella, 2010). In Italy the vaccination against HPV is
offered free of charge and on an active basis to pre-adolescents
when they are twelve years of age, as defined in the Agreement
between the Ministry of Health and the independent regions/
provinces dated 20th December 2007, in compliance with the
indications provided by the World Health Organisation and on
the basis of the regulations contained in the Guidelines of sev-
eral industrialized countries (Bartolozzi et al., 2007; Friedman,
Kahn, & Middleman, 2006; Agreement between the Govern-
ment, Regions, Independent Provinces of Trento and Bolzano
concerning “Strategies for the active offer of the vaccination
*This study was supported by grants from the Italian Ministry ofInstruction
University and Research (Anno 2008- prot. 20087YEJ55_002).
L. ELISA ET AL.
against infection from HPV in Italy” dated 20th December
2007, World Health Organization, 2006). As far as the cohort
of twelve year olds is concerned comply with the strategies of
preventive vaccination but they are diversified according to
Regions with regards to the other adolescent cohorts and poli-
cies of co-payment. The Agreement has left the confrontation
open in order to consider the opportunity of extending the offer
of vaccination between 13 and 18 years of age and from the
start of the campaign between Regions it offers active and free
vaccination to a second cohort of over 12 years of age (the
Piemonte and Valle d’Aosta Regions to sixteen years olds and
Friuli Venezia Giulia to fifteen year olds) and the Basilicata
Region to four cohorts (12, 15, 18 and 25 years of age). Subse-
quently another 4 Regions (Tuscany in 2009 and Liguria,
Marche and Puglia in 2010) extended the offer to a second
cohort (Giambi, 2011). Investments in primary prevention will
generate its results on a long term basis and, at the moment, it
should not interfere with current cytological screening pro-
grammes; on the long term, however, the very best strategies of
integration of primary and secondary prevention must be as-
sessed. Any possible changes in the preventive practices should
be shared with health professionals and with the general popu-
lations; this is even more valuable in the case of a sensitive
topic as sexually transmitted diseases. In this context it is vital
that adolescents also investigate into the scientific knowledge
of infection from HPV and the methods of prevention. The
majority of adolescents, in fact, discover their sexuality with
insufficient assistance and information, often provided by in-
competent and inadequate sources. Sometimes, even though the
information is available it may appear to be authoritarian or it
imply an opinion or, even, appear not to be compliant with the
values of youngsters, their mentality and their lifestyles. An
efficient way of facing this problem is represented by peer
education. Since 1990 peer education has been one of the most
diffused methods for the implementation of health promotion
intervention amongst youngsters. It is based on an innovative
course in the information/prevention process aimed at the
younger groups of the population, with direct effects on the
behavior of the youngsters involved, activating them as creators
and protagonists of the programmed action and as witnesses
and diffusers within the peer group. The prevention experience
carried out during the past years has highlighted the failure of
behavior change, according to which direct relations between
an increase in knowledge and change in behaviors was hy-
pothesized and they have always highlighted the efficiency of
the model of self-empowerment that, focusing on the personal
involvement of the beneficiaries of the intervention, aims at
modifying risky behavior (Spizzichino, 2005). However, peer
education has been considered a potentially efficient strategy in
order to launch intervention finalized at the prevention of sexu-
ally transmitted diseases in youngsters; the influence that
youngsters can have on the sexual behavior adopted by their
peers has been documented (World Health Organization, 2007;
Hoffman, Sussman, Unger, et al., 2006). This represents a
channel of communication through which well trained and mo-
tivated youngsters undertake educational activities with their
peers (Adamchak, 2006; United Nations Population Fund and
Family Health International, 2005). Peer education is frequently
carried out as it has been designed in a simple and convenient
manner to transmit information with a very broad reference
target, in a simple and economic manner. In reality, if per-
formed correctly, peer education requires attentive planning,
coordination, supervision and resources (Adamchak, 2006).
The positive assessment, not only on a short term but most of
all after one year, shows if peer education, an educational
method based on the involvement of youngsters’ right from the
early stages of the project, can be applied in order to modify
their behavior and maintain it in time.
The main objective of the research is to: evaluate the effec-
tive outcomes in a 1-year follow up of a randomised commu-
nity test of the effect of peer health education on primary pre-
vention knowledge, attitude and behaviours towards HPV
among adolescents with reference to previous documents from
the same test (Ferrara, Langiano, & De Vito, 2012).
Therefore the complete investigation will be presented with
the objective of promoting adhesion to the primary and secon-
dary prevention programmes and providing information on the
characteristics, potentials and limits of the vaccination. The
target chosen is represented by secondary school students due
to the high percentage of individuals belonging to the adoles-
cent age group (Baseman & Koutsky, 2005; Louvanto, Rintala,
Syrjänen, Grénman, & Syrjänen, 2011; Piana, Sotgiu, Castiglia
et al., 2011; Pieralli, Fallani, Lozza et al., 2011; Vaccarella,
2010) and because, not having participated in the active offer of
vaccination through a greater awareness, they may submit
themselves spontaneously (Do & Wong, 2012).
Between September 2010 and June 2012, we carried out in-
vestigations into KAB (Knowledge, Attitudes and Behaviour)
in a sample of secondary school students, on infections from
HPV and vaccinations and their sexual habits. Peer education
intervention was carried out and 2 follow-ups were carried out
after the educative intervention, the first after four months (T1)
and the second after one year (T2).
The schools involved formed our sample and were chosen on
the basis of contacts that the researchers involved have with
members of the school boards.
Researchers from the Laboratory of Hygiene of the Depart-
ment of Human and Social Science and Health from the Uni-
versity of Cassino and Southern Lazio (Central-Southern Italy),
sent an invitation to participate in the project to members of the
Boards of two Technical Colleges and two Secondary Schools
in Cassino but only the Secondary School specialising in Clas-
sical Studies and the Secondary School specialising in Scien-
tific Studies, academic institutions with a long and deep-rooted
history of collaboration with the University, in the execution of
health promotion activities among adolescents (Ferrara, Gentile,
Merzagora et al., 2004; Ferrara, De Vito, Langiano et al., 2006;
Ferrara, Langiano, Di Tiene et al., 2010; La Torre, De Vito,
Martellucci et al., 2002; La Torre, De Vito, Capelli et al., 2003).
In order to guarantee maximum collaboration of teachers in
the investigation, researchers contacted the board of directors of
each of the two schools before carrying out the educational
intervention, illustrating all phases of the project ranging from
the objectives, the methods and the execution times.
Copyright © 2012 SciRes. 1139
L. ELISA ET AL.
Copyright © 2012 SciRes.
The study was approved by the boards of each of the schools
involved as well as by the parent representatives who received
information regarding the contents of the programme, the
method used and the layout of the study.
with more detailed information on research and on how to fill
in the form.
Randomization process has been performed according to re-
vised recommendations for improving the quality of reports of
parallel group randomised trials (Kenneth, Schulz, Altman, et
al., 2010). Through a random extraction, a sample of 900 stu-
dents was selected, belonging to both of the colleges.
The pre-questionnaire was handed out by the peer educators
to all of the students in December 2010 (T0) during normal
Educational intervention in the experimental sample was car-
ried out between February and May 2011.
This sample represents 64.3% of the total students population
attending the colleges involved. Between June and November 2011 (T1) the peer educators
handed out the post-questionnaire to students belonging to the
experimental group and to students belonging to the control
group and also belonging to the control group.
By using this extraction method based on cluster randomisa-
tion, the research team assigned the experimental condition to
323 students, including execution of peer education interven-
tion, and the control condition to 577 students (Figure 1). In June 2012 (T2) both groups were given the post intervene-
tion questionnaire (1-year follow up).
In order to check the efficiency of the intervention of peer
education with regards to the change in opinions and beliefs on
HPV, questionnaires were distributed before and after the in-
tervention by the peer educators (T0 basic, T1 first follow up,
T2 1 year follow up) to the experimental group and to the con-
In order to avoid identification of the students and to guaran-
tee their anonymity, they were asked not to indicate their names
but they had to make up their own nickname.
The nickname used had to be the same in the pre-question-
naire and in the post-questionnaire; this allowed researchers to
proceed with pairing of the three questionnaires.
Families of the students were also informed through a pres-
entation letter illustrating the objectives of the study and expla-
nations related to the questionnaire were provided. Furthermore,
it contained contact details of the researchers of the Laboratory
of Hygiene of the University of Cassino and of Southern Lazio
who were available for any clarifications necessary.
The teachers were invited to leave the classroom during
compilation of the questionnaire and they were not involved in
the distribution and collection of the questionnaires.
Informed consent, necessary to participate in the study, was
achieved by parents for the students of less than 18 years of age
and by the students themselves if 18 years of age or more
through the use of a specific form.
A four page questionnaire was developed. The majority of
the items were structured in a defined set of possible answers or
within the control boxes (often/always/sometimes/never or
yes/no/don’t know). The questionnaire was made up of 30
closed questions, divided up into different topics and classified
Before giving them the questionnaire, students were provided
The CONSORT flow diagram on randomization process.
L. ELISA ET AL.
in three different sections:
1) Social-demographic section; including age, sex, city of
residence, number of brothers/sisters, level of education of
parents and their profession.
2) Section related to infection from HPV and its vaccination;
necessary for identification of the knowledge possessed with
regards to HPV and its vaccination, also extremely important
for purposes related to findings of behaviour compared with
execution of the vaccination.
3) Section dedicated to the assessment of attitudes and prac-
tices with regards to the topic of sexual health.
The questionnaires have been tested through the execution of
a pilot study carried out on a random sample of adolescents
from a secondary school.
The pilot study made sure that the questionnaires were perti-
nent and acceptable for the participants and that the level of the
language was appropriate. Following the pilot study, small
variations were made to the layout of the questionnaire.
Peer Education Intervention
Peer education intervention consists of:
1) Selection and training of 15 Peer Tutors chosen from
among the students attending the first year classes of the
Teacher’s Training Degree course in Social Politics and Social
Services from the University of Cassino and Southern Lazio.
2) A range of meetings for teachers acting as health refer-
ences for the schools involved, during which the objectives of
the research were explained and discussed; the methods of
enlisting of the sample were explained, the experimental group
on which intervention was to be carried out and the methods of
execution and the expiry date defined.
The students that showed greatest interest were invited to
take part in training courses as Peer educators including a range
of meetings and workshops held by researchers from the Labo-
ratory of Hygiene of the University of Cassino and of Southern
Lazio, by the doctor in charge of programmes from the Coor-
dination Centre of screening and by the doctor in charge of
paediatric consultancy at the Local Health Authority (ASL) of
the province of Frosinone.
Training destined for peer educators was developed, organ-
ised and managed by the researchers themselves and was char-
acterised by the obligation to attend.
In order for a peer educator to be classified as such, he must
have knowledge, skills and competence (Adamchak, 2006;
United Nations Population Fund and Family Health Interna-
tional, 2005; Supporting Community Action on AIDS in De-
veloping Countries, 2006; Pellai, Rinaldin, & Tamborini,
The training course was based on topics such as: peer educa-
tion, papilloma virus, the methods of transmission of the virus,
HPV vaccination, HPV test, Pap test, risky behaviour, safe
behaviour, consequences of the infection, symptoms and treat-
ment. The course included team work to face topics such as
facilitation, communication, basic consultancy, methods of
information (presentation, communication and personal devel-
opment, empathy and non judgmental attitudes, assertiveness,
self-esteem, group dynamics, sensitivity, general topics, so-
cial-cultural topics and finally economic trends).
The training intervention proposed was divided up into two
sessions, each one lasting 2 hours.
Activities were coordinated by the research managers who
identified the method of intervention in classrooms and they
defined the methods and articulation of intervention.
Intervention carried out in order to prevent infections from
HPV has provided information on the principles that character-
ise health education and medical education, focusing on the
adoption of risky behaviour by youngsters compared with the
problem in question.
The topics faced specifically refer to: epidemiologic data re-
lated to diffusion of the infection from HPV in Italy and
throughout the world; the methods of transmission of the virus;
HPV vaccination, HPV test, Pap test, risky behaviour and safe
At the same time as presentation of the topics mentioned
above, the importance of the involvement of adolescents in
planning prevention initiatives, with the objective of motivating
youngsters to active participation in the subsequent phases, was
During the intervention, in fact, the youngsters were offered
a whole range of techniques to facilitate communication, circle
time and brainstorming, for example, concrete examples on
how to handle class discussions, building discussion groups
with them (Landi, 2004; Croce & Gemmi, 2003). During im-
plementation of the intervention the peer educators, working on
the information provided to them, resumed the topics several
times, they stimulated adolescents to interact through informal
discussions and comments and they replied to the questions
The contents of group discussions was guided, providing the
peer educators with specific indications on how to pilot the
group itself. The teachers that attended the intervention stimu-
lated students to participate.
The latter took part in a training meeting before the start of
the activities included in the project and that provided them
with information on their contents and characteristics.
Through a whole series of meetings the peer educators inter-
acted with the teachers with the objective of monitoring project
development, its implementation, the difficulties encountered
and assessing efficiency.
The surveillance activities and the exchange of experience,
as well as the introduction of corrective measures allowed for
continuation of the programme in an even more efficient man-
Finally, an assessment process was carried out in order to
collect quality and quantity information on the learning courses
in which the students were involved during the various stages
of the intervention, to measure efficiency and effectiveness or
to prove the validity of the intervention itself (Barreto, 2005;
Derzon, Sale, & Springer, 2005). The final assessment of the
intervention was therefore developed through two follow-ups,
aimed at checking the permanence of the information that had
been transmitted “by the youngsters to the youngsters” through
the peer-to-peer channels and, most importantly, the changes in
their behaviour (Croce & Gemmi, 2003; Goodstadt et al., 2001).
Analysis of Dat a
The answers were analysed through the use of descriptive
statistics. Continuous data, normally distributed, was described
through the use of averages and standard deviations. However
category data was described using frequencies and percentages
and the groups (mothers vs. fathers among parents; women vs.
men among students) were compared according to cases using
Copyright © 2012 SciRes. 1141
L. ELISA ET AL.
χ2 or the Fisher test.
All of the analyses are two tail values and the p value
equivalent to .05 have been considered as significant.
The Odds Ratio (OR) and the intervals of confidence
equivalent to 95% (CI) have been calculated to measure asso-
ciations between the selected factors, chosen on the basis of
revision of the reference literature and the inclination of stu-
dents to be subject to vaccination against HPV.
The OR’s have been achieved through the use of multiple lo-
gistic regression, fixed by:
Age, sex and religion of the student; education and presence
of the parents; six of their brothers and/or sisters;
Average age of the first sexual relationship; the presence of
two or more partners; use of a condom.
The analyses have been carried out using Epi Info (version
Results and Discussion
In T0, the sample consisted of 900 students, in T1 650 indi-
viduals were interviewed and 617 in T2. The T1 sample con-
323 individuals belonging to the experimental group
577 individuals belonging to the control group.
The experimental group as well as the control group took
part in both of the surveys.
During the first follow-up, carried out after 4 months, 250
students had been lost. The reasons for non completion of the
study in question were:
Withdrawal from school (n = 7)
School absence (n = 243).
In June 2012 (T2), however the general sample consisted of
617 students (287) from the experimental group and 330 from
the control group (5 had withdrawn from school and 28 due to
The rates of withdrawal were similar (p < .05) in the two fol-
low-ups and in both groups.
Description of the Sample
During the basic time (T0) the average age of the sample was
16.6 ± 1.4 SD, with no drastic differences between the individ-
ual of the experimental groups and the members of the control
Furthermore, within the two groups, no significant differ-
ences were found in terms of distribution between sexes (70.8%
in girls from the experimental group; 65.7% in the control
1.7% of the students that did not indicate their sex were ex-
cluded from the gender analysis but included in the analysis
related to sexual experience.
The demographic data of students, including sex, age, num-
ber of brothers/sisters, religion, level and profession of their
parents, are indicated in Table 1, from which we can see that
the fathers are older than the mothers: respectively 49.3% and
33.2% were ≥50 years of age.
The majority of participants of the sample had just one
brother/sister (46.4; 55.8% brothers, 59.3% sisters); 39.9%
have at least one sister or brother of more than 18 years of age.
Distribution of students by social-demographic factors.
Total sample size 900 100
Male 298 33.1
Female 587 65.2
Missing 15 1.7
Means age ± ds 16.6 ± 1.4 ds
Catholic 780 86.7
Atheist 94 10.4
Other 5 .6
Missing 21 2.3
Number of siblings
0 387 43
1 418 46.4
2 70 7.8
>3 25 2.8
Educational level of fathers
Primary school 7 .8
Junior high school 74 8.2
High school 455 50.5
College Degree 337 37.5
Missing 27 3
Educational level of mothers
Primary school 11 1.2
Junior high school 61 6.8
High school 481 53.4
College Degree 332 36.9
Missing 15 1.7
Work activity of fathers
White collar worker 263 29.2
Self employed 317 35.2
Other 298 33.1
Missing 22 2.5
Work activity of mothers
White collar worker 210 23.3
Housewives 235 26.1
Other 435 48.4
Missing 20 2.2
Copyright © 2012 SciRes.
L. ELISA ET AL.
Personal Knowledge of HPV and Attitude to
Vaccination: The Experimental Group
This study, carried out on the middle-high class of the popu-
lation of a small area of central Italy, highlighted the fact that
adolescents still have many gaps with regards to knowledge of
infection from HPV and prevention of this infection through
vaccination. This can be found in data related to the experi-
mental group, with reference to T1, and from data related to the
control groups of T0, T1 and T2.
In fact, in the basic time, the majority of students of both
sexes (64.6%; 95% CI 58.9% - 70.0%) have stated that they are
aware of the HPV virus, with statistically significant differ-
ences in terms of gender (female 73.6% vs. males 43.0%; p
< .01). In the first post-questionnaire statistically significant
differences in terms of gender were confirmed, the percentage
of males that state that they are aware of HPV (65.0%; p < .01)
has increased, as an increase in the percentage of male and
female students has been registered (84.4%, 95% CI 79.3% -
88.7%). At T1 the percentage related to knowledge increased
drastically (91.3%, 95% CI 87.3% - 95.9%) in both sexes.
These results were in line with the results achieved in similar
students on a national and international level (Di Giuseppe,
Abbate, Liguori et al., 2008) proving the incisiveness of the
technique of peer education in the expulsion of information
guided by the “peer to peer” channel. Furthermore, our data
confirms how the application of new educational methods
based on the involvement of youngsters right from the begin-
ning of the project may help to change their behaviour and it in
time (De Santi, Ranieri Guerra, Morosini et al., 2008).
The methods of execution of peer education intervention
have maintained a spirit of dynamism and adaptation according
to the class context (dispersion or cohesion), favouring a direct
and communicative attitude by the peers, mainly based on rela-
tional aspects (Nizzoli & Colli, 2004).
The peers have therefore acted as facilitators of communica-
tion, despite having to handle a spatial and relational context
passed down by academic teaching; as far as the children are
concerned, they have welcomed with pleasure the possibility of
using moving space, therefore allowing themselves to be
stimulated by curiosity, spontaneity and spirit of initiative
(Boda, 2001; Marmocchi, 2004).
Furthermore, 67.4% of students who had already had sex
were aware of HPV, without any significant differences in
terms of sex and age.
There were no significant differences related to sex not even
between those who stated that they were aware of HPV with
respect to the level of danger perceived (54.7%; 95% CI 48.9%
-60.4%; 75.8% females vs. 40.2% males; p < .05) and how the
virus is transmitted (83.4%; 95% CI 78.8% - 85.7%; 76.0%
females vs. 34.0% males; p < .01).
In the post-questionnaires of T1 and T2, the percentage of
those who recognised the seriousness of the effects on health
caused by infection from HPV increased and reached, respec-
tively, 64.8% (95% CI 58.5% - 70.7%) and 72.0% (95% CI
65.5% - 74.9%). An increase in the percentage that stated that
sex was the main method of transmission of the virus was also
registered (T1; 89.1%, CI 84.6% - 93.7%) and (T2; 96.2%, CI
89.5% - 99.8%) without registering differences due to gender.
Only 14.7% of the individuals interviewed were aware of the
risk of infection from HPV (95% CI 10.9% - 19.2%) and if this
is divided up by gender, the percentage related to the perception
of risk is much higher in women (90.7% females vs. 49.3%
males; p < .01), as confirmed by the post-questionnaires
(T1-24.7%; 95% CI 18.6% - 29.9%; 82.1% females vs. 44.9%
males; p < .01; T2-29.8%; 95% CI 22.7% - 34.8%; 83.2% fe-
males vs. 46.8% males; p < .01).
Therefore a good part of the sample appears to underestimate
the possibility of contagion of the virus, consequently, they
underestimate the anti HPV vaccination as an important means
of prevention. This thought becomes an important indication
for future programmes of information and training on the
Papilloma Virus that should be developed with the objective of
increasing the awareness of using the vaccination against the
Papilloma Virus to provide protection against the infection and,
therefore, from CCU.
In fact, with regards to knowledge related to vaccination,
71.1% (95% CI 64.9% - 77.4%) of students in T0, 83.9% (95%
CI 75.6% - 87.8%) of students in T1 and 85.8% (95% CI 79.5%
- 91.7%) in T2, were aware of the fact that it also vents CCU;
once again, girls (72.4%) were the ones most aware of this
compared with boys (47.8%) (p < .01), as can be seen in other
studies (Sopracordevole, Cigolot, Lucia et al., 2009).
Apart from their families (40.0%; 95% CI 33.2% - 47.1%),
youngsters have received information related to HPV from
school (21.5%; 95% CI 16% - 27.7%), from friends (19.0%;
95% CI 13.9% - 25.1%) and from the family doctor (17.1%, CI
95% 13.2% - 2.1%).
Students state that they need more information on the anti
HPV vaccination (86.5%; 95% CI 81.9% - 90.3%); a need that
is much higher in girls (75.2%, p < .01).
More than half of the individuals interviewed (54.6%; 95%
CI 49.0% - 60.1%) would like to receive further information
from discussions with experts; in particular this has been stated
by girls (69.4%, p < .05). A small, yet still important percent-
age of boys (13.5%), do not believe that they need further in-
formation as they are not interested in this subject.
With the first administration, more than half of the students
(52.6%; 95% CI 48.4% - 60.6%), mistakenly believe that the
vaccination against HPV also provides protection from other
sexually transmitted infections; this belief is even higher in
women (33.7%, p < .01).
In T1 this percentage is less, equivalent to 32.9% (67.9%;
95% CI 63.4% - 70.8%); while in this regard boys are still in-
correctly informed (22.9%, p < .01). One year after the inter-
vention (T2) the percentage generally reached 28.9% (95% CI
23.4% - 33.8%).
In the pre-questionnaire, 14.1% of the girls stated that they
had been subjected to the vaccination; 71.8% of them belonged
to the group of girls who had never had sex. The educational
intervention carried out has had a positive effect on vaccina-
tions; in fact the percentage of people vaccinated increased
from 14.1% to 17.5%, as can be seen from the post-question-
naire T1 and 19.2% in T2.
Significant associations have emerged between being sub-
jected to the vaccination and the medium/high level of maternal
education (84.6% p < .05) and the presence of a sister aged
between 10 and 16 (36.1%, p < .01).
Approximately 70.0% of the female students involved in the
pre-questionnaires, 82.3% in the post-questionnaires and 89.5%
in the final follow-up are aware of the fact that the HPV vacci-
nation should be administered before the start of sexual activi-
ties; a much lower percentage (55.6%) has been registered in
male students in the pre-questionnaires, with a slight increase in
Copyright © 2012 SciRes. 1143
L. ELISA ET AL.
Copyright © 2012 SciRes.
the post-questionnaires (T1 64.6% and T2 69.9%) with signifi-
cant differences in terms of sex (p < .01).
The fear of contraindications from administration of the vac-
cination is one of the main reasons for resistance to the vacci-
nation (10.5%, 95% CI 7.5% - 14.5%) followed by the absence
of knowledge on the objectives of the vaccination itself (9.0%,
95% CI 6.2% - 12.7%).
After the educational intervention these percentages fell (re-
spectively 8.0%; 95% CI 5.2% - 11.7% and by 7.7%; 95% CI
5.1% - 11.3%) and confirmed in the final follow-up.
From an analysis of the pre-test, 41.6% (95% CI 34.7% -
48.7%) of the girls expressed a desire to administer the vacci-
nation against HPV, a percentage that reached 59.7% (95% CI
52.6% - 64.6%) in T1 and 67.6% (95% CI 63.4% - 71.4%) in
Prevention of Cervical Cancer has represented the most inci-
sive factor on the decision to be subjected to this (at T0 the
percentage is 38.6%; 95% CI 33.3% - 44.1%; however, in the
post-questionnaires the percentage reaches, respectively, 66.6%
(95% CI 52.6% - 64.6%) in T1 and 76.5% (95% CI 71.5%
77.1%) in T2.
From the survey carried out, we can see how important it is
that information related to prevention of infections from HPV
should be supplied during the 10 and 13 age group. With re-
gards to this aspect, a percentage difference between the
pre-questionnaires and post-questionnaires has been found (re-
spectively 39.7%; 95% CI 34.1% - 45.4% and 43.9%; 95% CI
37.5% - 50.3%); furthermore, a statistically significant differ-
ence in terms of sex has been found (43.8% females vs. 29.8%
males, p < .05). The low percentage of female adolescents that
consider themselves to be potentially at risk of contracting HPV
should be due to the low perception of the high diffusion of this
infection, as previously proved in other studies (Caskey, 2009;
Chan et al., 2009).
As far as male students are concerned, apart from having
identified a lower level of knowledge with regards to the HPV
virus, a high diffusion of thought according to which the males
believe that the infection does not involve them, has been
This is not surprising as the Papilloma Virus and the vacci-
nation itself have been publicised almost exclusively with re-
gards to the prevention of cervical cancer and it is still to be
clarified if males should be vaccinated.
Not even knowledge represents a sure indicator of behaviour
change in health care, however it is an essential and vital pre-
supposition to identify the age group that requires the most
information (Di Giuseppe, Abbate, Liguori et al., 2008; Piana,
Sotgiu, Castiglia et al., 2011; Pieralli, Fallani, Lozza et al.,
Table 2 provides the results achieved from an analysis of
data related to knowledge, behaviour and attitudes of the stu-
dents and the differences found between the two groups (ex-
perimental and control) with reference to the pre-questionnaires
and post-questionnaires in T0, T1 and T2. This shows that
knowledge as well as attitude related to the vaccination in-
creases in the follow-up after 4 months and continues to in-
crease in the 1-year follow-up. This would lead us to presume
that peer intervention has stimulated students to acquire more
Main differences in the knowledge of and attitude to HPV infection and HPV vaccination between experimental group and comparison group.
Intervention group (323) Comparison group (577)
T0 (%)T1 (%) T2 (%) T0 (%) T1 (%) T2 (%)
Knowledges of HPV infection and vacci nation
Have you ever heard about HPV? (Yes) 64.6 84.4 91.3 72.6 73.9 74.3 .02
Do you think that HPV could be dangerous?
(Yes) 54.7 64.8 72.0 64.5 63.8 62.9 NS
How is HPV infection transmitted?
(Sexually) 83.4 89.1 96.2 80.3 81.6 82.1 NS
Do you think HPV infection might concern you?
(Yes) 14.7 24.7 29.8 20.1 19.9 20.3 .05
Have you ever heard of HPV vaccination? (Yes) 71.1 83.9 85.8 72.2 73.7 72.9 .001
Which is the main aim of HPV vaccination?
(Prevention of cervical cancer) 52.6 67.9 77.8 49.2 49.9 47.7 .01
When is HPV vaccination recommended?
(Before beginning of sexual activity) 68.1 79.2 90.1 73.3 74.6 77.3 .02
Personal attitu des towards HPV
vaccination (Only female) (225 = 70.8%) (374 = 65.7%)
Have you been vaccinated? (Yes) 14.1 17.5 19.2 11.9 12.1 12.3 .03
Do you want to have HPV vaccination? (Yes) 41.6 59.7 67.6 40.1 40.5 40.9 .001
If you wanted to have HPV vaccination, what
would be your reason?
(Prevention of CCU)
38.6 66.6 76.5 35.4 36.7 38.3 .03
Note: *Significant differences in knowledge, attitude and behaviour between intervetion and comparison group (p); NS: non significant.
L. ELISA ET AL.
information and, in any case, has made them much more sensi-
tive to the topic (Barreto, 2005; Derzon, Sale, & Springer, 2005).
Table 3, however, illustrates the results of the analyses of
From this analysis we can see how the level of education of
parents, the religion of the students and the fact that they have a
sister are all factors associated with greater inclination to the
Apart from this a significant association has been found be-
tween the level of education of the mother and the fact that they
individual has already been vaccinated (medium/high level of
maternal education 84.6% (OR = 3.7; 95% CI: 1.9 - 7.1; p
Furthermore, it was established that the students that de-
clared a religion other than Catholic or atheist, are less willing
to be subjected to the HPV vaccination (OR = 0.6, CI 95% 0.4 -
0.9, p < .05) compared with Catholics.
The inclination to be subjected to the HPV vaccination is as-
sociated with other factors such as: the sex of brothers/sisters
(the presence of at least one sister aged between 10 and 16);
36.1%, OR = 1.6, CI 95% 1.4 - 1.9, p < .05); inclination in
general to vaccination (OR = 13.1, 95% CI 9.7 - 17.8, p < .05);
and knowing that the HPV vaccination aims at preventing cer-
vical cancer (OR = 3.3, CI 95% 2.6 - 4.1, p < .05).
Among the students aware of the fact that infection from
HPV can affect their own state of health, greater inclination to
vaccination against HPV has been registered, regardless of the
sex considered: males (OR = 3.2; 95% CI: 2.6 - 4.1; p < .05);
females (OR = 2.8; 95 % CI: 1.6 - 3.9; p < .05).
In the control group no substantial differences have been reg-
istered with regards to knowledge among T0, T1 and T2.
The students included in the control group state that they are
aware of HPV in a percentage of 72.6% (95% CI, 67.8% -
77.9%) in T0. The results of T1 are very similar (73.9%, 95%
CI, 65.9% - 82.1%) and also of T2 (74.3%, 95% CI, 68.8% -
81.0%). In this case also there is a high percentage of students
in the pre-questionnaire (80.3%) and also in the two post-ques-
tionnaire (81.6% at T1 and 82.1% at T2) that identify sex as the
main method of transmission of the HPV virus.
As far as the question regarding the perception of risk is con-
cerned, we can see how, in T0, 79.9% (95% CI, 74.6% - 84.8%)
of the individuals interviewed do not believe to be at risk of
infection from HPV. The situation is almost identical in T1 and
in T2; in reality the percentage reaches 80.0% in both of the
One aspect that should be underlined is that almost half of
the students from the control group (48.6%) were aware of the
fact that HPV can be the cause of the onset of cervical cancer, a
percentage that almost superimposes the one registered in the
T0 experimental group (51.9%). Finally, 11.9% in the pre-
questionnaires and 12.1% and 12.3% respectively at first follow
up and last follow up have stated that they have been vacci-
Sexual Behaviour: The Experimental Group
34.4% (95% CI, 28.9% - 40.3%) of the students stated that
Associations between selected socio-demographic factors, personal beliefs and attitudes of students to vaccinating themselves against
Independent variables OR (95% CI)
Educational level of mother
Mother high/medium level
Mother low level (reference group)
3.7 (1.9 - 7.1)*
Catholicism (reference group)
.6 (.4 - .9)*
The gender and age of the siblings (at least one sister aged between 10 - 16 years)
No (reference group)
1.6 (1.4 - 1.9)*
The propensity to vaccinations in general
No (reference group)
13.1 (9.7 - 17.8)*
Knows that HPV vaccine is aimed at preventing cervical cancer
No (reference group)
3.2 (2.6 - 4.1)*
Thinks that HPV might concern you?
No (reference group)
No (reference group)
3.8 (1.6 - 3.9)*
4.0 (2.6 - 4.2)*
Note: *p < .05; CI, Confidence Interval; OR = Odds Ratio. 1ORs from multivariate logistic regression models, adjusted for gender and religion of the
student, education of the parents and presence, age and gender of their brothers and/or sisters.
Copyright © 2012 SciRes. 1145
L. ELISA ET AL.
they were in a relationship (41.4% of females vs. 18.5% of
males). 31.0% of the individuals interviewed (95% CI 25.9% -
36.7%) stated that they have had sex (males 73.3% vs. females
26.7%: p < .05), therefore they have been classified as sexually
Among the students classified as sexually active (93.3%), the
presence of a higher level of information on the HPV virus was
found compared with students that are not sexually active
(84.0%); (p < .01).
Knowledge of infection from HPV is much higher in women
(80.8%) compared with men (19.2%); (p < .01).
Among the sexually active students, 39.0% (95% CI; 29.0% -
49.0%) see themselves as an individual at risk; while, out of the
non sexually active students, only 9.0% (95% CI, 5.0%, -
12.0%) believe that they risk contracting infection from HPV.
The average age of a first sexual experience has been Regis-
tered at around 14.9 ± 1.02 years with statistically significant
differences in terms of gender (males 14.6 ± 1.02 years vs.
females 15.1 ± 1.03 years; p < .05).
Among the students that declared that they are sexually ac-
tive, 67.9% stated that they had had just one partner (67.9%, CI
56.8% -77.6%); 16.7% declared that they have had two and
9.5% stated that they have had more than three partners.
The males stated that they have had more than three partners
(83.3%); however, women stated that they have had just one
(43.8%). This leads us to confirm a statistically significant dif-
ference between men and women (p < .05).
66.7% (95% CI, 57.7% - 75.9%), declare that they use con-
traceptives. The most common form of contraception used is a
condom (97.5%, 95% CI, 93.4% - 99.5%).
The girls that stated that they rarely or never use condoms
would like to be subjected to the vaccination against HPV.
Paradoxically, it seems that the girls that have shown the great-
est inclination to the HPV vaccination may benefit less from the
vaccination. In reality, in light of the proof available on the
HPV vaccination, these girls may already be infected by HPV
due to their high risk sexual behaviour (Piana, Sotgiu, Castiglia
et al., 2011; Pieralli, Fallani, Lozza et al., 2011; Vaccarella,
67.9% (95% CI, 62.5% - 73.0%) claim that they have spoken
about their own sexuality with friends while half of the sample
has not discussed this subject with its parents, unless the topic
was introduced by the parents themselves (36.5%); (95% CI;
30.8% - 42.5%) or in the case of specific problems (14.2%);
(95% CI; 10.3% - 18.9%).
The girls that declared that they have had more than 3 part-
ners (9.8%, OR = 2.4, CI 95% 1.1 - 4.9, p < .05) were more
willing to have the HPV vaccination while the ones that stated
that they do not use a condom (36.9%, OR = .5; 95% CI .3 - .6,
p < .05) appeared to be less inclined to refuse the HPV vaccine-
tion (Table 4).
The main factors associated with the inclination of the stu-
dents to accept the HPV vaccination were: the presence of at
least one sister in the family; being favourable to vaccinations
in general; knowing that the objective of the vaccination was to
As highlighted in other studies (Do & Wong, 2012; Bar-
tolozzi, Bona, & Ciofi, 2007) there is a positive association
between the perception of risk of infection from HPV and the
inclination of male and female students to be subjected to the
Association between sexual behaviours and attitudes of students (fe-
male) to being vaccinated against HPV1.
Independent variables OR (95% CI)
Has a boyfriend/girlfriend?
No (reference group)
.3 (.1 - .6)*
Has had sexual inter course?
No (reference group)
.7 (.4 - .9)*
How many persons have you had se x ual
1 partner (reference group)
1.7 (.7 - 3.8)*
2.4 (1.1 - 4.9)*
Do you use condom?
No (reference group)
.5 (.3 - .6)*
Note: *p < .05; CI, Confidence Interval; OR = Odds Ratio. 1ORs from multivariate
logistic regression models, adjusted for gender, mean age of the first sexual inter-
course, to have two o more partners, using condoms.
This data strengthens the idea that the starting point for the
success of the HPV vaccination campaign should be to increase
the level of awareness of adolescents on this subject, highlight-
ing in particular the aspects related to the frequency of infection
However, factors such as having a boyfriend or already hav-
ing had sex are factors associated with a reduced inclination to
vaccination among female students, perhaps because a high
percentage of them are aware of the fact that they should have
received the vaccination before starting sexual activities (Mas-
sini, Marona, Di Pinto et al., 2010).
All of this highlights the need for a training programme fo-
cused on epidemiology related to infection from HPV in con-
nection with different age groups and the associated risk factors
so as the prove that the vaccination is useful, even after the start
of sexual activities, as long as the individual has not yet been
infected (Caskey, 2009).
From a general analysis of data, the efficiency of the inter-
vention has emerged: the experimental group (and only this one)
has changed the perception of casualness in terms of health. At
the end of the intervention more than before, health protection
has been strictly correlated with behaviour, life styles and per-
sonal choices. This finding has been correlated with specific
objectives of the intervention; furthermore, peer education has
been assessed and compared with the changes expected after
the intervention, after four months and after one year, to check
if and how much the knowledge, but most importantly, the
behaviour had really changed and been maintained in time.
Our figures have shown that greater understanding with re-
gards to infection from HPV and the possibility of preventing
CCU thanks to the vaccination may increase the inclination of
youngsters to having the vaccination. Furthermore, information
related to the HPV test and information related to the vaccina-
tion require the use of efficient communication and constant
This should involve, most of all, women identified as the
ones that need information the most and are included in the age
group at risk, in which the diffusion of information is vital to
Copyright © 2012 SciRes.
L. ELISA ET AL.
favour aware choices (Baseman & Koutsky, 2005).
Our research confirms how friends, in the age group of ado-
lescents, have a positive effect on the adoption of lifestyles of
friends of their own age.
The meetings were very useful to stimulate youngsters to-
wards communication among equals with regards to HPV to
teach them not to delegate their own health and to create the
competence (life skills) that allow them to be directly responsi-
ble for their own health, not only the beneficiaries but also the
protagonists of the intervention (Marmocchi, Dall’Aglio, &
Zannini, 2004; Bertini, Braibanti, & Gagliardi, 2006).
Throughout the entire course, the participants showed the
ability to work in a group and to be an important part of it, il-
lustrating their willingness and enthusiasm, desire to under-
stand and learn, desire to collaborate and a sense of responsibi-
lity. Situations in order to overcome the generational commu-
nication barriers necessary to implement truly efficient preven-
tive intervention (De Santi, Ranieri Guerra, Morosini et al.,
The style of participation of the meetings also allowed stu-
dents to face topics related to adolescent life and relationships
with people of the same age and with adults. Group discussions
favoured observations on risky behaviour and the underlying
reasons, as well as a comparison of prejudices, shared mentali-
ties and the social prototypes of the world of youngsters con-
nected with this infection, in order to understand how these
elements affect the choice of behaviour. On the basis of these
considerations and observations illustrated by students and
teachers, we can deduce that participation in this experience has
strengthened the sense of empowerment in the participants as
well as self-trust and the pleasure of being useful to people of
their own age and having given them a chance to exchange
comments on the topic of HPV (Pellai, Rinaldin, & Tamborini,
2002; De Santi, Ranieri Guerra, Morosini et al., 2008).
The limits of this investigation are the ones that can be cross-
checked in a randomised and controlled study and they can be
compared with representativeness of the sample in terms of the
external validity of the study. In reality the controlled random-
ised study may result in distorted results if the methodological
rigour is missing (Kenneth, Schulz, Altman et al., 2010).
Recruitment was limited to one single province and the sam-
ple of schools essentially represents the medium-high class of
Even though the proportion of individuals interviewed was
high and despite the fact that those schools participated, whose
headmasters were mainly interested in infection from HPV and
the promotion of health, the presence of a bias selection cannot
be excluded, due to the different social-demographic character-
istics of the schools that participated, compared with the ones
that did not take part in the project.
Moreover, one can not non consider of the various ages must
be made among the individuals aged between 15 and 18 with
the other variables such as the cultural models or experience,
resulting in the layout of a composite or differential variable
research, so much so that the results of the analyses should be
interpreted in descriptive terms but with the technique still re-
maining the same. Furthermore, if on the one hand the fol-
low-up time of one year can wait for the effective permanence
of information and the variation in changes, on the other hand it
is inclined to being deeply affected by other events or other
information channels that, during that specific period of time,
could have intervened for/against the knowledge and the global
attitudes expressed by the individuals (Kenneth, Schulz, Alt-
man et al., 2010). However, the results achieved are coherent
with the initial hypothesis of research.
Our results highlight that the approach to peer education has
been warmly welcomed by students; this can facilitate the fu-
ture adoption of similar projects.
The results discussed in this study is on the positive evalua-
tion of short-term and one year denotes that the positive results
persist and even increase in the time. In reality, the long term
persistence of the effects produced is a vital aspect. Therefore,
another assessment on how this programmes can be carried out
using, for example, recall sessions, will be necessary.
On the contrary, the greatest strong points of this study are
the large dimensions, the availability of information received
from students and inclusion in the sample of male and female
individuals, but also the assessment of efficiency one year after
It is difficult to come into contact with adolescents especially
if discussions refer to the same ones discussed in this document
and with regards to which girls/boys do not understand the real
risk, as they are too far away; in fact the consequences deriving
from the adoption of behaviour considered to be risky can only
be seen on the long term (Croce & Gemmi, 2003). For several
years the various studies carried out on peer education have
come up with substantial changes in knowledge and in the atti-
tude between peer educators and those reached by the interven-
tion (Massini, Marona, Di Pinto et al., 2010). The representa-
tives of youngsters are the youngsters themselves and peer
education may be much more efficient in health promotion
compared with traditional educational techniques (Pellai &
Boncinelli, 2003; Landi, 2004).
The first important thing is what one wants to say but the
second important thing is how one says it!
The means is the message! (Nizzoli & Colli, 2004; Pellai &
Boncinelli, 2003). Youngsters listen and believe in youngsters
but adults and institutions are the ones that possess the knowl-
edge: working together in a combined manner is the best way
of helping youngsters to preserve their health.
Another important aspect that it is important to remember
here refers to the need to carry out an efficiency assessment on
long term intervention. The follow-ups, the first one four
months and the second one year after the end of the educational
intervention illustrate the efficiency of the training intervention
through the use of peer education (Barreto, 2005; Derzon, Sale,
& Springer, 2005). The study carried out highlights important
differences between the experimental group (subject to the
intervention) and the control group (not subject to the interven-
tion) in terms of knowledge but, most importantly, in behaviour
and it proves how the application of new educational methods
based on the involvement of youngsters right from the initial
stages of the project can help them to change their behaviour
and maintain it in time.
Finally, by working in this direction it is possible to create
social campaigns using languages, methods and images taken
from the world of youngsters, with greater probability of
achieving this target with greater effectiveness (Pellai, Rinaldin,
& Tamborini, 2002).
Our research confirms how friends, in the adolescent age
group, have a positive influence on the adoption of lifestyles of
Copyright © 2012 SciRes. 1147
L. ELISA ET AL.
their peers. Adolescents live in a transition period, searching for
support in their peer group in order to complete their growth
stages, as confirmed by our quality figures. The intervention in
question therefore appears to have produced positive results:
the majority of students would like to have further meetings
with their peers (De Santi, Ranieri Guerra, Morosini et al.,
Strengthening the resources in each youngster means helping
them to make a small step forward towards their future: training
through information allows them to acquire a fair overview of
the chances available to grow in a healthy and free manner
(Goodstadt et al., 2001).
In general terms, after a careful examination of the results,
we can state that with regards to the topic involved in our re-
search, the two samples have come up with significantly dif-
ferent averages: the individuals from the experimental group
have generally had better levels of performance compared with
those from the control group (Barreto, 2005; Derzon, Sale, &
Springer, 2005). In the two follow-ups, with regards to correct
answers, the youngsters belonging to the experimental group
have proved to have greater familiarity of information related to
the HPV virus and vaccination and a consolidation of changes
in their behaviour.
We are grateful to the peer educa-tors and the schools par-
ticipants for their cooperation and assistance.
All procedures were approved by the appropriate academic
Conflict of Interest
The authors declared that they have no conflict of interests.
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