Effect of Peer Education on Knowledge of Human Papilloma Virus and Cervical Cancer among Female Adolescent Students in Benin City, Nigeria

A key source of reproductive health information for the adolescent is her peer. In fact, some studies have evaluated this approach in disseminating information on cervical cancer to adult women in Nigeria with good results. In Nigeria, disseminating health information is challenging, as trained and knowledgeable health educators are few, and often not enough funds are provided for such activities. The aim of this study was to assess the knowledge of female secondary school students about cervical cancer and the human papillomavirus (HPV) vaccine to determine if their knowledge could be improved using peer-to-peer transfer of knowledge.

The HPV vaccine has not yet been deployed in the National Programme on Immunization (NPI) in Nigeria, but it is available for a fee. In addition to the current high cost of the vaccine, adolescence, the age group for which the vaccine is recommended, has particular characteristics that may be barriers to optimum uptake of the vaccine. Adolescents may resist any dominant source of authority, such as parents, and they may have problems when attempting to acquire information about age-related concerns. Studies have shown that lack of information about cervical cancer and HPV vaccine is a major contributory factor to not being vaccinated.

As part of this intervention study, the knowledge and awareness of female students of 4 secondary schools were assessed using a pre-tested self-administered questionnaire prior to the training of some of the students (peers). One of the authors of this study gave a lecture to the peers on cervical cancer and HPV that included key information; each peer was given a flier to reinforce this information. Within 2 weeks of the training, each peer delivered a mini-lecture on the subject to her classmates using the flier as a guide.

Within a week of the peers delivering their lectures, using the same questionnaire, information on cervical cancer and HPV was obtained from 30% of the students in each school. The questionnaire used for the pre- and post-test at the seminar as well as for collecting the baseline data in the schools and post-peer training in the schools was pretested at a secondary school that was not involved in the study ("school cohort").

There were 1,337 students who responded to the baseline questionnaire, while 1,201 responded to the post-peer training questionnaire. Overall, mean knowledge score prior to training was 12.94 ± 9.23, and this increased significantly to 53.74 ± 10.69 following peer training p < 0.0001. The mean knowledge score improved by 47.45 percentage points among those in the seminar cohort compared to 41.67 percentage points among those in the school cohort. Some specific findings related to knowledge:

• More than 90% of the respondents did not know that HPV was the cause of cervical cancer. In general, there was low awareness of cervical cancer among the students prior to the training, with only 198/1,337 (14.8%) and 18/124 (14.5%) of the school cohort and seminar cohort (those who heard the seminar), respectively, having ever heard of cervical cancer. There was a statistically significant increase in awareness to 1,174/1,337 (97.8%) among the school cohort after the intervention p < 0.0001. Awareness about cervical cancer being common increased significantly following the intervention.
• None of those in the seminar cohort knew that cervical cancer was associated with multiple sexual partners and that cervical cancer could occur in anyone who had had sexual activity. Also, none of them knew that cervical cancer could occur in married women, older women, young girls, and women who have had babies. Knowledge about the risk factors increased significantly following training at the seminar (p < 0.0001).
• There was a statistically significant improvement in the proportion of students in the seminar cohort who considered abstinence a preventive strategy following the training (p = 0.007), but the improvement following peer training in the school cohort was not statistically significant (p = 0.21).

The researchers stress that health education programmes for adolescents need to emphasise risk factors for acquisition of HPV and cervical cancer, which are also significant for other sexually transmitted infections. Only about 3% of the students studied had engaged in sex. The low sexual activity among these students provides a window of opportunity for providing them with sexuality information and health education prior to sexual debut. They are also at an opportune stage during which they can receive the HPV vaccine.

The researchers reflect: "Different methods have been proposed for the delivery of peer education....The method used in this study was that of formal delivery in a class setting. The advantage of this method is the ability to increase knowledge in a large number of persons in a short period of time with minimal resources. The impact of this strategy is likely to be more as the adolescents were encouraged to discuss the information received with family members and with friends who are not in their schools. The use of key points to enhance recall and its use for peer training is an important method to emphasise important must-know facts."

In conclusion, this study finds that peer training is effective in improving knowledge and awareness of secondary school students about HPV and cervical cancer. It is recommended that all schools should use the strategy for disseminating information garnered from seminars outside their schools in which their students participated.