Human Papilloma Virus-related risk factors for adolescent and young women

Maria Cristina de Melo Pessanha Carvalho^I; Ana Beatriz Azevedo Queiroz^II; Maria Aparecida Vasconcelos Moura^III; Sérgio Correa Marques^IV; Bianca Dargam Gomes Vieira^V; Dennis de Carvalho Ferreira^VI

^I PhD in Nursing. Nurse at the Ministry of Health. Rio de Janeiro, Brazil. E-mail: mcrismelo4@hotmail.com
^II PhD in Nursing. Associate Professor. Anna Nery Nursing School, Federal University of Rio de Janeiro. Brazil. E-mail: abaqueiroz@hotmail.com
^III PhD in Nursing. Full Professor, Anna Nery Nursing School, Federal University of Rio de Janeiro. Brazil. E-mail: maparecidavas@yahoo.com.br
^IV PhD in Nursing. Adjunct Professor, Nursing College, State University of Rio de Janeiro. Brazil. E-mail: sergiocmarques@uol.com.br
^V PhD in Nursing. Adjunct Professor, Aurora de Afonso Costa Nursing School, Fluminense Federal University. Niterói, Rio de Janeiro, Brazil. E-mail: biadargam@gmail.com
^VI PhD. Professor, Veiga de Almeida University and Estácio de Sá University. Rio de janeiro Brazil. E-mail: denniscf@gmail.com

DOI: http://dx.doi.org/10.12957/reuerj.2017.25823

ABSTRACT

Objective: to identify risk factors for human papillomavirus (HPV) infection associated with behaviors and attitudes of adolescents and young people at an upper secondary school in Rio de Janeiro. Method: in this quantitative, descriptive study conducted from May to November 2012, data were collected by questionnaire from 128 women from 15 to 24 years old, and received descriptive statistical treatment, which highlighted demographic, economic and behavioral variables. The study was approved by the research ethics committee of the Anna Nery School of Nursing, São Francisco de Assis School Hospital, Rio de Janeiro Federal University (protocol No. 030/2011). Results: the data indicated resistance to condom use in sexual relations: 81.3% of the women never used condoms in their relationships. Another of the participants' characteristics highlighted by the study was the use of a condom in the first relation only. Female condoms were not used by the group studied. Conclusion: the study shows epidemiological data and important sociocultural issues that indicate the need for in-depth research, as well as the nurses' playing a role in new educational strategies designed to be effective in changing behavior and attitudes in these population segments.

Keywords: Women's health; papillomaviridae; risk factors; condom.

INTRODUCTION

Human Papillomavirus (HPV) infection has been described as the most frequent sexually transmitted disease worldwide. This infection affects preferentially the genital organs such as the vulva, vagina, cervix, penis, perianal areas and also the oropharynx. If left untreated, it may progress to cancer¹. HPV is grouped into genotypes considered of low and high oncogenic risk, in an attempt to establish a relationship between the persistence of the infection, viral types and cervical cancer². HPV is recognized as the main risk factor for cervical cancer, but it cannot be considered the necessary cause for the development of this type of malignant neoplasm³.

HPV infection is one of the most frequent sexually transmitted diseases in the female population⁴. About 157,000 new cases are registered in Brazil each year, and around 80% of the sexually active women in the world will be infected by one or more types at some point in their lives. Thus, HPV infection is an important public health problem in this population segment⁴. Several factors may contribute to HPV infection, including those related to the viral nature such as subtypes and viral load; and those related to the host such as onset of early sexual activity, multiparity, use of oral contraceptives, precarious hygiene habits, smoking, inadequate feeding, infections by other sexually transmitted pathogens such as Human Immunodeficiency Virus (HIV), Clamydia Trachomatis and Type 2 Herpesvirus³. The number of sexual partners that the individual has had during life stands out as the most important factor associated with the acquisition of virus ⁵. Women under the age of 25 are vulnerable to HPV infection, but persistent infection occurs in women over 50 years of age with immunological deficits and concomitant risk factors⁶.

It is worth noting that in the case of contagion, 25% of the adolescents present HPV infection during the first year after sexual initiation, pointing out that the possibility of contact with this virus increases progressively⁷. Young women experience a number of changes that occur not only in their bodies, but also in the social and psychological spheres. Depending on their experiences, as for example with HPV infection, these changes can generate a lack of identity, disrupt sexuality and affectivity, and hinder the maturation process⁸. Adolescent sexuality is considered a dimension of the social context and is also understood as a public health problem because of the risks arising from unprotected sex. The precocity of menarche, the growing exploitation of the topic (sexuality) by the media, greater sexual freedom and precarious socioeconomic conditions⁹ are also pointed out. The lack of information and the false idea of not being vulnerable to the situation also prevent young people from adopting preventive measures against risk factors¹⁰.

Given this scenario of vulnerability to HPV, it is of fundamental importance that health professionals know the profile and differences of behaviors and attitudes among these individuals, in order to build proposals and strategies with the purpose of reducing morbidity and mortality due to precursor lesions and cervical cancer.

Based on these arguments, this article aimed to identify the risk factors for HPV infection associated with the behaviors and attitudes of adolescents and young people of a high school unit in Rio de Janeiro.

LITERATURE REVIEW

HPV infection is considered the most common sexually transmitted disease in the world. More than 200 types of viruses have been described and are distinguished from each other based on the sequence of Deoxyribonucleic Acid (DNA)¹¹. It is an epitheliotropic virus, considered a causal agent of cervical cancer and produces oncoproteins that modify cellular behavior¹².

The relationship between persistent HPV infection and some viral types and cervical cancer has been established with aid of molecular biology techniques. These viral types preferentially infect the genital organs (vulva, vagina, cervix, penis and perianal areas) as well as the oropharynx. However, although HPV is recognized as a fundamental risk factor for cervical cancer, it cannot be considered as the single cause for the development of this type of malignant neoplasm¹³.

Viruses that infect the genital area are classified into HPV types of low and high oncogenic risk, which are identified by numbers. The highest risk are those classified as 16, 18, 45, 31, 33, 35, 52, 58, 59, 56, 51, 39, 68, 73 and 82, and the viral types 16 and 18 are the most frequent in adolescents and young women. HPV types 16 and 18 are associated with High-Grade Intraepithelial Lesion, epidermoid carcinoma and adenocarcinoma of the uterine cervix, as well as anal carcinoma. It is noteworthy that 99.7% of all cases of cervical cancer result from a history of persistent infection¹⁴.

In relation to low risk viruses, these are associated with benign lesions (6, 11, 40, 42, 43, 44, 54, 61, 70, 72 and 81), with emphasis to the types 6 and 11 that are related to condylomata acuminata, responsible for more than 90% of the cases of anogenital warts ¹⁵.

In this context, understanding the relationship between HPV infection and the risk factors associated with this type of infection is essential for the practice of the health professionals, whose role is to establish strategies, such as educational actions among adolescents and young people, to prevent cervical cancer and the acquisition of HPV.

METHODOLOGY

This is a descriptive study with a quantitative approach carried out in a state secondary school of the Municipality of Rio de Janeiro, Brazil, between May and November 2012. The population was composed of 128 women selected from group of women aged 15 to 24 years. The participants were in the age group defined by the World Health Organization as youth - from 15 to 24 years - and were enrolled and attending the study scenario ⁴. We decided to divide the participants into two groups, also based on the Brazilian Institute of Geography and Statistics, which defines young people as individuals aged 15-24 years¹⁶.

The first group was composed of 64 adolescents belonging to the second phase of adolescence, which is from 15 to 19 years of age; and the second group was composed of 64 young people and in the age group of 20 to 24 years of age¹⁶. This division is justified on the premise that the subjects' behaviors and attitudes emerge from the different life stages ¹⁷.

A structured questionnaire containing data on personal and socioeconomic characteristics, expressed in the variables age, race/color, schooling, marital status and family income, was used for data collection. Regarding characteristics related to risk behaviors and attitudes towards HPV, the variables of interest of the study were: presence of current sexual partners, onset of sexual intercourse, number of sexual partners in the last 12 months, use of the female and/or male condom, frequency of use of condoms, use of oral contraceptives, multiparity and smoking.

Participants were invited to join the study and the interviews were scheduled and carried out in a private room in the school itself. The information collected was stored in a computerized database in the Excel software the Microsoft Office package 2003. Subsequently, data were tabulated and submitted to descriptive statistics. The analysis considered the absolute and percentage frequencies, confronted with the scientific literature on the subject.

The norms of Resolution nº 196/96 of the National Health Council in force at the time of the elaboration of the research project were observed. The project was submitted to the Research Ethics Committee of the Anna Nery Nursing School/São Francisco de Assis School Hospital of the Federal University of Rio de Janeiro, and was approved under protocol nº 030/2011. As recommended, the data were collected after the study participants and by parents and/or guardians of children under 18 years of age signed the Informed Consent Form.

RESULTS

A total of 128 volunteer young women participated in this study, among 64 adolescents and 64 youngsters. The age group between 17-19 years prevailed among the adolescents, corresponding to 53.1%, while the age group comprised between 20-22 years (59.4%) prevailed in the group of youngsters. As for the educational level, the first year of high school prevailed in in both groups , with 40.6% of the adolescents and 43.7% of the youngsters. Regarding the marital situation, 93.8% of the adolescents reported being single, while 46.9% of the youngsters reported being married or common-law married. See Table 1.

TABLE 1: Socioeconomic characteristics of the adolescent and young women participating in the study. Rio de Janeiro Brazil. 2016. (N = 64, per group)

(*) The value of the minimum wage at the time of study (year 2012) was R$ 622.00, equivalent to 234 US dollars.

Half of the adolescents had from three to four minimum wages as family income, a fact that was different among youngsters, among whom the income of up to two minimum wages prevailed. Regarding the socioeconomic characteristics, the white self-declared race/color was predominant among the adolescents, being brown more frequent among the youngsters with 46.9%, as shown in Table 1.

At the time of data collection, 62.5% of the adolescents and 84.4% of the young women had sexual partners; with regard to the number of sexual partners in the last 12 months, 37.5% of the adolescents declared 0-1, followed by 31.3% who had among 4 to 5 partners. In the young segment, 37.5% reported having between 4 and 5 partners, followed by 25.1% with 2 to 3 sexual partners. See Table 2.

TABLE 2: Characteristics related to risk behaviors and attitudes of adolescent and young women towards the human papillomavirus. Rio de Janeiro Brazil. 2016. (n = 64, per group).

Regarding the use of condoms, 62.5% of the adolescents and 56.3% of the youngsters reported having used only male condoms, but in relation to the frequency of use, the –use only in the first relation prevailed among adolescents, with a frequency of 25.1%; and among youngsters, the irregular use (sometimes) prevailed, with a frequency of 28.1%. It is worth noting that 37.5% of the adolescents and 43.7% of the young women had never used any condoms in their sexual relations, as shown in Table 2.

In the variable "Use of oral contraceptives", 43.7% of the young women reported using contraceptive pills, while 71.9% of the adolescents stated that they did not use this method. Regarding parity, 3.2% of the adolescents and 9.4% of the young women had given birth three times or more; the majority in both groups was nulliparous (89% of the adolescents and 62.5% of the young women). Regarding smoking, 89% of the adolescents and 76.6% of the young women did not report this habit.

Regarding the characteristics related to risk behaviors and attitudes, the predominant age of onset of sexual activity was between 14 and 17 years in both groups (43.7% of the adolescents and 37.5% of the young women); the minimum age was 9 years and the maximum was 24 years. It should be noted that the profile of the sample indicates the predominance of the age group from 20 to 22 years, brown skinned, enrolled in the first year of high school, single, and with a family income of 3 to 4 minimum wages, as shown in Table 2.

DISCUSSION

The prevalent age between the two study groups was 17 to 22 years, being this age group the most likely to be infected by HPV. In fact, age is among the most important risk factors for HPV infection, with a higher prevalence among adolescents and young people aged up to 24 years⁷. It is emphasized that the peak of prevalence in this segment can be explained by the greater alternation of partners and early onset of sexual activity. In this context, HPV infection can affect adolescents and youngsters at the onset of sexual activity, a phenomenon that may be transient and that most of the time regresses spontaneously¹⁸.

With respect to race/color and predisposition to HPV infection, the information is scarce in the literature. Research has indicated that black and brown races are more susceptible to the prevalence of carcinogenic HPV infection¹⁹. The present study indicates that the white race predominated among the adolescents, and among the young women, the brown color was the one that was more prominent, although there was no statistically significant difference between groups.

The insertion of in the school environment is a determining factor for the construction of knowledge about certain health problems. The relationship between schooling and vulnerability to HPV is considered a predisposing factor to HPV infection: the lower the schooling, the greater is the prevalence of the infection²⁰. Little information or even lack of information are still considered one of the main barriers to the control of sexually transmitted diseases. The lack of education influences the perception of risk^{21, 22}.

Another aspect that deserves to be highlighted, in terms of risk factors for HPV, is family income. It was noticed that in both groups, participants with a low income, or between two and four minimum wages, predominated. The results of the present study show that half of the adolescents had a slightly higher income, corresponding to three or four minimum wages. This can be explained by the fact that the adolescents live with their parents and/or relatives, who work and support them. As for the young women, we observed that there was a prevalence of lower income among them, equivalent to two minimum wages, since in their case, many reside with their partners and children, and only the partner is the provider of the household. These data are in line with a research study conducted by the Brazilian Institute of Geography and Statistics that showed that about 13% of families with adolescents and young people live with an income of one quarter of the minimum wage, and 36.2% with half of the minimum wage¹⁶.

It should be noted that a low-income population with social and gender inequalities faces obstacles to adopt attitudes favorable to health care²³.

Regarding the marital status and sexual partners, although 93.7% of the adolescents were single, 62.5% had sexual partners such as boyfriends or casual partners in the data collection period. In contrast, 46.8% of the youngsters were married or common-law married, and a total of 84.4% had a sexual partner. In view of these data, it is evident that stable union was more prominent among the young women, due to the age factor, than among the adolescents. Stability in a relationship is now considered a risk factor for HPV infection. The fact of having a fixed partner leads to sexual deprivation because the use of condoms is despised after the relationship becomes stable⁸. This usually happens when the relationship is no longer eventual but becomes more permanent, which implies a decrease or even absent use of condoms.

This can occur because of trust or even submission to the partner when it comes to negotiating the continuity of condom use in the relationship. A permanent partnership is defined as a single partner for a longer period of time²⁴. However, occasional partners, as expressed by the adolescents and youngsters, are also considered risk factors for HPV, both for multiplicity of partners and for non-use of condoms.

Multiplicity of partners was another risk factor found in this study. Among the adolescents, 50% had had two to five sexual partners, while among young women this number increased significantly to 62.6%. Thus, the two groups studied are subject to vulnerability due to the frequent exchange of partners, which brings a greater chance of acquiring HPV, especially when the condom is not used in all relations. The increased number of sexual partners allows for different sexual practices, increasing the possibility of acquiring the infection and the degree of vulnerability²⁵.

In this same direction, it is important to mention the portion of participants who did not use condoms, incurring greater exposure to HPV. Most women reported never having used condoms. The use of condoms among women is a subject that can be attributed to the affective-sexual relationship, contributing to the decision to use the condom or not ⁸. This is reinforced by the fact that only 25.1% of the adolescents and 18.7% of the young people had used male condoms in the first relation. It is noticeable that the use of condoms can be linked to the intimacy and trust between partners²⁶.

Moreover, the use of refractory condom was also mentioned in the data, by 21.8% of the adolescents and 28.1% of the young women. This discontinuous use may be explained by factors such as not liking to use condoms because of the belief that it implies loss of sexual pleasure, because of the belief that the person is not in a situation of vulnerability, forgetfulness, difficulties to acquire condoms, and difficulty to control the sexual impetus typical of adolescents and young people¹⁰.

As for the type of condom used by the participants, only the male condom was mentioned. This reinforces that the female condom is little known, and it is still being disseminated, a fact that also corroborates the submission of women, for they need to negotiate the use of male condoms ²⁶. The predominant age of onset of sexual activity was 14 to 17 years, corroborating another study in which among a total of 8,649 women, 74% reported having first had sex between 14 and 19 years¹⁵. The age of sexual initiation is an important factor when studying the vulnerability of HPV, since the early onset of sexual activity is one of the factors for the acquisition of HPV. This is due to the fact that immature uterine/ cervical cells of the adolescents are more receptive to this virus at the onset of sexual life²⁷. Furthermore, the time of exposure to the virus in this part of the population is enhances the risk situation²⁸.

In the case of oral contraceptives, the majority of participants did not use this contraceptive method. However, comparing the two segments studied, the young women were the ones that stood out the most with regard to the use of the pill with 43.7%, against only 28.1% of the adolescents.

In view of the use of contraceptives, and in the case of the condition of stable union that a large part of the young women 46.8% already experience, the concern with unwanted pregnancies prevails instead of with the possibility of contracting a sexually transmitted infection. It is worth mentioning that the prolonged use of oral contraceptives increases the risk of developing cervical carcinoma in women with HPV, since they contain hormones such as dexamethasone, progesterone and estrogens that intensify the genetic expression of HPV²⁹.

With regard to the number of births, a small number of young women (9.4%) calls attention for having already given birth three or more times. Multiparity is considered a risk factor for HPV infection, which may result from vaginal trauma during delivery and effects of hormonal changes in the cervix³. Studies have highlighted the increased prevalence of HPV in women with three to four deliveries and that multiparity can increase by two- or thre-fold the risk of cervical cancer precursor lesions and cervical cancer itself in women infected with oncogenic HPV types ^{25, 30}.

In the case of smoking, most participants did not present this habit, a fact that is very positive. Smoking is considered as an important risk factor for the development of cervical cancer in women who are carriers of oncogenic HPV. This is due to the presence of carcinogenic metabolites of tobacco in cervical secretions, which may lead to the persistence of the virus^26,31.

CONCLUSION

The objective of the study was fully achieved, as it was possible to survey the socioeconomic characteristics and behaviors of the adolescents and young women that contribute to the vulnerability of these groups to HPV. It was possible to identify that the study participants presented behavioral characteristics of susceptibility to HPV, such as low adherence to the use of male condom and early onset of sexual activity. However, when comparing the two study groups - adolescents and young women -, we concluded that there are differences in relation to risk factors, such as multiplicity of partners, use of oral contraceptives and multiparity, which were more prevalent among young women.

Considering the behaviors of adolescent and young women reported in this study, it can be inferred that there is a fragility of educational actions regarding the valuation of the social and cultural context of individuals in relation to protective measures against sexually transmitted infections such as HPV. More research is needed targeting young women and the possibility of being infected with HPV and development of cervical cancer.

Emphasis should be placed on the participation of nurses as health professionals in the search for new strategies for preventive and educational actions, aiming at effective change in the behavior and attitudes of these population segments, recognizing not only statistical data but also biopsychosocial issues. The study contributes to innovations and to the need to implement strategies for preventive practices, valuing knowledge and making it possible to meet the needs of adolescents and young women regarding protection against sexually transmitted infections.

As a limitation of the study, only adolescent and young women participated in the study, not allowing the comparison between male and female individuals regarding socioeconomic issues and behavioral attitudes towards HPV infection.

However, there is space for further studies to be carried out with the males, investing in the search for other risk variables, as well as investigating the causes and consequences of these behaviors that lead to the situation of vulnerability.

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