Socio-demographic characteristics of participants
The examination of participants’ characteristics showed that 92% (n = 23) were female, the mean age of participants was 19.79 ± 0.85 (min:18-max:22) and 44% were 20 years old. It was found that 40% of the students lived in the Aegean region and regarding economic status, 76% of them had equal income and expenditure. Based on the examination of the educational status of participants’ parents, it was determined that 72% of their mothers and 64% of their fathers were primary school graduates. When asked about who makes the medical decisions for them in their families, 80% of the students stated that they make the decision themselves.
1.2. Participants’ opinions and experiences regarding HPV infection and HPV vaccine
Based on the conceptual framework of the study, three main themes and eight sub-themes were generated as a result of the thematic analysis of the participants' perceptions and opinions on HPV infection and HPV vaccine (Fig. 1).
'Insert Fig. 1 here.'
Theme 1. Perception of HPV infection/vaccine
According to the participants, they were sensitive to the fact that HPV infection would harm them and that they could be protected from this disease by HPV vaccination. However, they agreed that many factors related to HPV infection and vaccination created a perception of barriers. The majority of the participants stated that because HPV infection is a sexually transmitted disease, it causes social prejudices and is perceived negatively.
The participants believed that that people generally hid the disease (n = 15), they were afraid to share it with others not to be stigmatized (n = 15), and that public awareness should be raised because HPV infection is regarded as a fearful/shameful disease (n = 18). It was found that the majority of the participants refrained from getting HPV vaccine to protect them from sexually transmitted diseases (n = 19). The reasons for these reservations were identified as social pressure (n = 8), prejudices (n = 13), taboos and fear of being stigmatized (n = 10), cost of vaccination (n = 12), society's lack of knowledge and insensitivity about the disease and the vaccine (n = 13) which were reported as the barriers by the nursing students.
Sub-theme: Social prejudices/perceptions regarding the transmission route of the disease
Although most of the participants stated that they have a positive attitude towards HPV vaccination and protection from HPV infection, they emphasized that they may encounter a negative attitude due to the value judgments of the society and the customs and traditions of the geography they lived in. They stated that they would refrain from being vaccinated against a sexually transmitted disease due to the fear of stigma, and that they would hide it because they were ashamed to share it openly.
“…. Here, there is more pressure on females compared to males stemming from the concept of honor, adultery, and Islam…. In many sexually transmitted diseases, people are stigmatized immediately, and they do not share it because they are afraid of being stigmatized. (ID-14, 21 years)
“If it happened to me … I can't tell that to my family, because of their values. … Everyone needs to know this as well; people need to be vaccinated… It is because of Islam, it is regarded as adultery… not everyone talks about it openly, they are ashamed, they have reservations…” (ID-4, 22 years)
The participants stated that they did not take initiatives on prevention methods because the public lacked knowledge about HPV infection. They reported the existence of social prejudices regarding the transmission route of the disease and that these prejudices should be changed. Some participants stated that they avoided talking about this issue with their families and friends for fear of verbal and physical violence.
“… Since people do not know much about this infection, they do not resort to preventive methods … they increase the risk of transmission much more … discussing such things within the family, sharing it with others creates reservations … I think these discussions can even lead to domestic violence.” (ID-5, 19 years)
Sub-theme: Problems related to vaccination/perceptions regarding the vaccine
The majority of the participants emphasized that the public should be informed about the methods of protection against HPV infection and vaccination. They believed that informing individuals about the diseases against which the HPV vaccine provides protection, its effects and side effects would contribute to the spread of vaccination. Some participants also stated that they wanted to have the HPV vaccine, but they could not have it due to social judgments and negative feedback.
“…we know that the HPV virus is sexually transmitted … I believe that when the person talks about it with his/her family … they may stop him/her from being vaccinated, they will not allow him/her to do it.” (ID-21, 20 years)
“… I think people with awareness would want to have this vaccine, I would like to have it done myself… social judgment, beliefs can be a factor in not having the vaccine … people may have reservations… frankly, I would have reservations myself…” (ID-9, 20 years)
Some participants believed even if awareness was raised for vaccination, it would not be possible to reach the vaccine in low-income populations. Some participants also reported that individuals living in small settlements may not be able to access the vaccine even if they wanted to, since the cold chain conditions required for the storage of the vaccine can only be provided in large settlements. Lack of information/ignorance about vaccination, high cost of vaccination, and the lack of access to vaccines in rural areas were reported as the barriers to vaccination by the nursing students.
“… the cost of the vaccine is a huge factor, a big barrier… the fee is really too much for a vaccine… really difficult regarding the cost of the vaccination …” (ID-19, 20 years)
Theme 2. Perceived Severity
Participants were aware of the serious consequences of HPV infection, an important risk factor for cervical cancer. They believed that primary prevention of this infection included prevention of polygamy (n = 4), use of condoms (n = 8), attention to personal hygiene (n = 10), not sharing personal items (n = 3), refraining from sexual intercourse with infected individuals (n = 3) and periodic screening for cervical cancer (pap-smear and HPV-DNA test) (n = 6) in addition to vaccination. In addition, it was found that the nursing students perceived the severity of the disease and thought that public awareness should be raised (n = 18) so that individuals in the society could feel responsible for their health and develop behaviors that protect their health through preventive methods.
Sub-theme: Use of prevention methods
In line with the information, they had and learned about HPV infection, the participants were aware that serious measures should be taken to prevent the disease. They stated that due to the sexual transmission of the disease, monogamy, genital hygiene, regular gynecologist controls, vaccination, increasing knowledge and awareness about the disease and vaccine would be effective in primary prevention of HPV infection and cervical cancer.
“…Regular check-ups should be done, I believe that use of condoms is necessary, and vaccinations should be covered by the state…" (ID-1, 19 years)
“… in our society… I think that even going to gynecologists creates some reservations… I think condom use… polygamy… and seeing a gynecologist regularly regardless of gender when sexual life starts would affect protection to a great extent (ID-5, 20 years)
Sub-theme: Health responsibility
Participants stated that they could take responsibility for their behaviors related to protecting and improving their health. In this context, they believed providing information and support about the transmission route of HPV infection, its symptoms and treatment and the types, access and cost of HPV vaccine was necessary for health. At the same time, they stated that they were aware of their responsibilities as prospective parents who will raise future generations to make efforts for the development of individual determinants of health.
“...I would like to learn the differences between HIV virus and HPV virus, I would like to compare the two. Afterwards, I would like to know if there is a cure, what kind of treatments are possible, whether there is a precise treatment or it is only suppressed, the cost of the treatment, where I can get the vaccine...” (ID-5, 19 years)
“... We are all parents-to-be. if we have awareness… we can vaccinate our children too… I do not have concerns about the vaccine…. I have no reservations about the vaccine.” (ID-1, 20 years)
Theme 3. Suggestions and requests/facilitators
For the primary prevention of cervical cancer at the individual and public level, the participants made recommendations to implementing the methods of protection against HPV infection and to have the HPV vaccine. They also had some demands for the realization of these suggestions. In addition, they emphasized that it is necessary to eliminate social judgments, to increase knowledge and awareness, and to provide easy access to the vaccine to share responsibility and increase the motivation regarding these suggestions and demands. The participants stated that sexual health education should be provided (n = 17) with the belief that if the knowledge and awareness level of the society increases, prejudices will decrease. They also affirmed that it would be more appropriate to provide sexual health education within the family (n = 3), during secondary education (n = 3) and in high school (n = 4). They emphasized that informing the public would definitely increase the level of awareness and facilitate the spread of vaccination (n = 16). Some participants reported that especially young people (n = 6), families (n = 2) and the public (n = 16) should be informed. They also suggested using social media/TV (n = 5) and public spaces (n = 4) as platforms for providing relevant information. Some participants requested that information be provided by nurses (n = 6) and family physicians (n = 3) as well as reducing the cost of the vaccine, covering the cost of the vaccine by the state and making sure that the vaccine would be accessible in all rural/urban areas to facilitate access to the vaccine.
Sub-theme: Awareness raising
The participants communicated that raising awareness about HPV infection and vaccination to prevent cervical cancer would contribute to early diagnosis. In addition, they believed the use of audio-visual media would be motivating in encouraging participation in vaccination and screening in the society. They declared that awareness could be created by drawing the public's attention to protection from HPV infection and vaccination through public service announcements.
“They realize the existence of such infections after they have quite developed, after they have progressed to cancer. But then it's too late. I think the current youth, …. should be taught about this and their awareness should be increased as soon as possible.” (ID-1, 20 years)
“…. If advertisements are made about these as public service advertisements ... We can put out various advertisements or videos in order to raise awareness about the subject in social media ... In large shopping centers ... We can provide information about it, …” (ID-21, 20 years)
Sub-theme: Vaccine access
Participants requested ease of access to the vaccine to overcome the cost and transportation barriers in front of HPV vaccination. They believed as long as vaccines were accessible, nationwide vaccination would become widespread. They stated that family health centers can reach individuals easily and vaccine awareness can be created by preparing and distributing written materials about vaccination to ensure widespread vaccination.
“…I think everyone should be able to afford the amount. The next factor bringing the vaccine to each city….” (ID-19, 20 years)
“…this is a public problem literally, and in family health centers… I think that way vaccination can be encouraged. ….Frankly, I think that when people become more aware, they will look kindly upon the vaccine.” (ID-12, 20 years)
“… First, I think the price is a very effective factor about the HPV vaccine… I think vaccination will increase even more as long as there is state aid. Apart from that, I think that vaccine awareness can be increased by distributing brochures or things like that in health institutions or similar places. “ .” (ID-10, 20 years)
Sub-theme: Providing information
The participants emphasized that sexual health education would increase the knowledge level of the public since HPV infection is a sexually transmitted disease. In addition to those who thought that providing sexual health education individually would be more appropriate, others affirmed that this education should be given to parents as well as children and young people together with their families. Some participants, on the other hand, suggested that sexual health education should be provided at schools during the secondary education period, since the age of vaccination is 11 years, and above which is the period of adolescence. As the participants were nursing profession candidates, they emphasized nurses’ significant role in informing the society and their competence in providing support and contribution as well as knowledge.
“In my opinion, such courses should be provided on this subject, especially at schools. Because people can't learn such things from their families because it's shameful, they can't talk about such things..." (ID-3, 19 years)
“……first, and awareness of children should raised after raising awareness of the parents…” (ID-14, 21 years)
Sub-theme: Changing social judgments
The participants reported that the society was biased towards HPV infection and vaccination and suggested using different approaches to change this situation. They stated that the pressure of the society should be reduced, the feeling of shame should be overcome and the fear of stigma should be eliminated first to change social judgments. They stated that increasing the level of education, knowledge and awareness would be motivating and facilitating factors in the realization of these approaches.
“…… I would love to have this training with my family, especially when my parents, that is, my first-degree relatives are with me. Then it will break down all prejudices because it is given by a health worker after all.” (ID-5, 19 years)
“… a website could be set up… whether it's a nurse or a doctor, whether it's about the vaccine or the disease…..being able to talk to them live, I would like something like that. …. it will be better in terms of accessibility and because it reaches many people, the prejudices and stigmatization of those people can be eliminated.” (ID-4, 22 years)