CHAPTER THREE: LITERATURE REVIEW
Theoretical Framework: Health promotion model
The Health Promotion model that was proposed by Nola J Pender (1982) was used to conduct this literature review (Akoulova, tsui, irwin, damme, & aguado, 2008). The model has been chosen because it provides the basic framework that is followed in health promotion activities. Establishment of health literacy levels and their effect on vaccination can be regarded as a health promotion activity.
The health promotion model (HPM) has been widely regarded as a counterpart to models that promote health protection. The model defines health as positive dynamic state that does not necessarily occur due to lack of disease (Nursing Theories, 2012). Health promotion activities should, therefore, seek to increase the levels of a client’s wellbeing (Nursing Theories, 2012). Health promotion takes into account that the fact that human beings use different dimensions to interact with the environment. The model mainly involves three areas that include: individual characteristics and experiences; behavior specific cognition and their effects; and behavioral outcomes (Nursing Theories, 2012). The health promotion model puts emphasis on the unique experiences that are encountered at the individual level, and there potential effect on succeeding actions. It also considers the fact that motivations can be drawn from a set of variables that determine our behavior. Health promoting behaviors should be able to result into an improved health and this defines the end point for the HPM (agosti & goldie., 2007).
The model can therefore be used in the current research due to the fact that increased health literacy inevitably results into improved health as the general public becomes aware of things that should be done to prevent and treat diseases. The knowledge of the presence of a vaccine that can be used to prevent human papilloma virus (HPV) infection is an activity that should be investigated within a framework such as the one outlined by the health promotion model.
The model will be an important tool for drawing several assumptions that are important to the present study. Such assumptions might include the following (Akoulova, tsui, irwin, damme, & aguado, 2008).
If individuals are made aware of the presence of HPV vaccination, then they can take necessary measures to ensure that they get vaccinated against the virus.
Social complexities subject people to different factors in the environment, some of which might be positive while others are negative. Knowledge on the negative aspects that might affect an individual’s health is important in the effort to prevent infections such as those that result from HPV infection.
Health professionals such as nurses can play an important role in providing vital information regarding the availability of treatment and prevention options. That way they will have a positive influence in the lives of individuals by helping them to deal with environmental hazards such as HPV.
The health promotion model (HPM) has its basis in several theoretical propositions that are relevant to the present literature review. The first proposition alleges that prior behavior, together with inherited and acquired traits influence an individual’s belief and practice of health promoting behaviors. The second proposition states that people will always engage in a behavior that can have positive effects on their health, and things that are perceived as barriers will affect commitment to action (Nursing Theories, 2012). The third most important proposition stipulates that people will be more willing to engage in behavior that promotes their health, when other entities model the behavior or expect it to occur, and provide the necessary support that is required to enable the behavior (Nursing Theories, 2012). Families, friends, and health care providers form a vital source of person to person influence that can either increase or decrease an engagement in health promoting behavior (Nursing Theories, 2012).
Research and Non Research literature
In this review, the use of research and non-research literature has been done concurrently. This is due to the fact that health literacy is a relatively new concept in which non-research data exists, as different stakeholders attempt to establish a standard that can be used to underpin acceptable international practice. Health literacy, as a health promotion concept is also remotely associated with any vaccination activity. Most research literature is found to have investigated a characteristic related to health literacy such as the lack of structures to ensure effective dissemination of health information, and not health literacy as a whole (andrus, sherris, fitzsimmons, kane, & aguado., 2008).
Additionally, concurrent use of research and non-research literature takes into account the fact that health literacy is a dynamic concept, whose elements are many and varied and whose determination cannot be exhausted within a single study (Gutierrez, Bertozzi, Conde-Glez, & Aleman, 2006).
Theoretically, health literacy (HL) is a relatively new concept in medicine. The topic has however gained a lot of momentum in the last five to six years, and this has been reflected in both policy and research agendas in many countries around the world. The spirited efforts can be reflected in the activities that were undertaken during the “36th Annual Meeting of North American Primary Care Research group” (Protheroe, Wallace, Rowlands, & DeVoe, 2009). In the annual meeting, several authors deliberated on the issue of “Studying Health Literacy: Developing an International Collaboration”. Countries like the United States and the United Kingdom presented detailed information regarding their current state of health literacy.
Many other deliberations have been initiated to identify research direction that can be used to identify international agendas. The efforts have been applied to various health disciplines including nursing, general medicine and psychology (Akoulova, tsui, irwin, damme, & aguado, 2008).
The process-knowledge model of Health literacy defines health literacy as the degree to which individuals can access, process and understand basic health information and services for the purpose of making sound health decisions. The institute of medicine also uses the same definition. It is the cognitive and social skills which determine the ability of individuals to access, understand and use information in ways that lead to better health. Health literacy is a relatively new concept in the health sector (Chin, 2011). Health literacy basically involves emphasizing on patient participation in healthcare; through accessing better health information so as to make more rational health decisions. The World Health Organization and other public health organizations in different countries have identified that health literacy is an important factor in the determination of population health. Low health literacy has been suggested as a worldwide problem and a global challenge for the twenty first century (Akoulova, tsui, irwin, damme, & aguado, 2008). Low health literacy has been identified to cause detrimental impacts on health and health outcomes. The topic of health literacy has gained a lot of momentum in the last five years, which has been reflected in both policy and research agendas in many countries around the world. Health literacy can be argued to be a product of health promotion. Health promotion outcomes represent those personal, social and structural factors that can be modified in order to change the determinants of health. Health literacy outcomes include improved knowledge and understanding of health determinants, and changed attitudes and views as pertains health behaviour (andrus, sherris, fitzsimmons, kane, & aguado., 2008). Health literacy is also characterized by improved self-efficacy in relation to defined tasks. Health education actions include education for health, efforts to mobilize people’s collective energy towards the advocacy and improvement of health (fisher, darrow, tranter, & williams, 2008).
A study was conducted by Chin et.al to identify the effects domain generalized processing capacity, domain general knowledge, and the domain-specific health knowledge for two known measures of health literacy (2011). One hundred and forty six adults who dwell in communities were included in the study, out of which 103 had been diagnosed with hypertension. The results of the study showed that adults who showed higher processing capacity scored better on all both scales (Chin, 2011).
Research has shown that individuals who are currently more health literate tend to be younger, female, educated, articulate patients of higher socio-economic status. Low health literacy has been observed to be prevalent among lower socio-economic groups, ethnic minorities and older people (andrus, sherris, fitzsimmons, kane, & aguado., 2008). Communication in clinical settings is highly dependent on literacy and numeric skill. It has been noted that differences in literacy and numeric skills causes significant variations in patients’ ability to obtain and apply health information (Akoulova, tsui, irwin, damme, & aguado, 2008). People with lower literacy levels are generally 1.5 to 3 times more likely to have poor health outcomes than people with higher literacy levels. Health researchers have raised issues on the current government health policies widening the existing inequalities gap between the most and the least advantaged in society. They argue that the current government health policies only benefit the educated and the well-skilled in society while discriminating against the uneducated and unskillful (scarinci, et al., 2010). Research identified practical health communication challenges, as most printed health information leaflets had a reading age higher than the average population. Such printed health information, therefore, only benefited a proportion of the society (Akoulova, tsui, irwin, damme, & aguado, 2008).
A cross sectional study conducted by Alex et.al on health literacy and cognitive performance among older adults established a relationship between health literacy and cognitive abilities. The study was conducted in number of senior centers within New York. During the study, health literacy was measured using the Short Test of Functional Health Literacy in adults (Alex, Federman, Sano, Wolf, Sui, & Halm, 2009). The findings of the study showed that health literacy was not insufficient in 24.3%, impairment due to immediate recall was observed in 20% of the cases investigated, delayed recall scored 15%, while verbal fluency had 9.9% while MMSE (Minimal mental status exam) was 17.4% (Alex, Federman, Sano, Wolf, Sui, & Halm, 2009).
Low literacy and numerical skills also contributes to the bias of access to the benefits of prescription medication. Health literacy, which is measured on the basis of health related word recognition and comprehension, is highly correlated to general literacy. Health literacy is also associated with cognitive abilities, including processing speed and working memory (Thomson, Thomas, & shroyer, 2008). Low-literate people are more likely to make mistakes while interpreting prescription instructions and warning labels (andrus, sherris, fitzsimmons, kane, & aguado., 2008). The use of more cost-effective generic prescribing may negatively affect patients with low literacy levels. The recently introduced choose and book system, where patients choose and book their preferred service from a list of offers, will even be more difficult for patients with low literacy levels. Low health literacy is positively correlated with poor diet, smoking and lack of physical activity over a wide age range. Low health literacy is also associated with lower involvement in health screening and later presentation of illnesses. Poorer understanding of health information is associated with high mortality among old people in England (fisher, darrow, tranter, & williams, 2008).
Interventions are being implemented to reduce the effects of poor health literacy through modified communication and improved service organization. Steps being taken to correct this situation include minimizing the use of technical language in printed health information materials while using lay terminology whenever possible. Also encouraged is the use of visual aids and teach-back communication techniques by medical professionals. Other interventions include simplification of dosage instructions and dosing regimens and interactive online educational programs between the medical professionals and the patients. The self-management of chronic diseases needs more advanced forms of intervention. Intensive intervention on health literacy has been observed to reduce disease severity (Thomson, Thomas, & shroyer, 2008). Notable results include improved diabetic control, lower rates of admissions to hospitals and mortality for patients with heart failure. More comprehensive health literacy measures are being developed, that will assess higher level capabilities such as interpersonal communication skills. Medical professionals are encouraged to assess the readability of such printed materials and see that such materials can be understood even by low-literacy people. It has been observed that medical professionals tend to overestimate patients’ reading capabilities causing anxiety among patients when being given prescription instructions. Reading difficulties, caused by anxiety and shame, might lead to higher levels of depression caused by low health literacy. Good interventions encompass improving patient knowledge and empowerment as well as sensitizing the medical professionals about the difficulties experienced by the patients and ways of dealing with these difficulties (tay, ngan, chu, cheong, & tay., 2008). Research shows that there is no statistical dependence between pre-existing chronic condition and health literacy.
As people grow old, they have a general decline in cognitive performance which occurs in the absence of frank dementia. This scenario was observed with over five million Americans who were over seventy years of age who experienced cognitive impairment without dementia. Such cognitive impairment can cause increased difficulties in performing necessary health tasks. Many elderly individuals are not identified for medical support within the healthcare circle because they experience mild cognitive impairment which is difficult to detect. Mild cognitive impairment is characterised by measurable memory loss without functional impairment, and can be diagnosed using neuropsychiatric assessments. Verbal fluency, an important cognitive ability, is also often impaired in old people without dementia. Impaired verbal fluency affects meaning derivation from text or oral communications, vocabulary access and inference making from long term information. Measures of abnormal cognition in old people are significantly associated with low health literacy (Akoulova, tsui, irwin, damme, & aguado, 2008).
A study done on 414 elderly Americans found that memory impairment and verbal fluency had a strong correlation with inadequate health literacy. This correlation was still strong even after excluding individuals with abnormal cognition. The association between cognitive impairment and low health literacy shows that conveying health information to populations at risk for cognitive impairment must be designed in such a way that it compensates for limited cognitive skills. Higher literacy skills have been seen to reduce the rate of cognitive decline in old people. Health information meant for the old must limit the demand for memory and verbal fluency in order for the communication to be effective (Thomson, Thomas, & shroyer, 2008). The use of familiar language and testing for comprehension are strategies that could also be incorporated. Medical professionals might also follow up patients to reinforce learning. The identified relationship between cognition and health literacy calls for major attention by medical professionals and policy makers because they both lead to undesirable health outcomes (Akoulova, tsui, irwin, damme, & aguado, 2008).
A study was conducted which investigated how processing capacity, general knowledge, and health knowledge relate to performance on the two most commonly used measures of health literacy: the REALM and the S-TOFHLA. It was observed that performance on both measures of health literacy were dependent on multiple cognitive abilities. It was observed that older adults with higher processing capacity and knowledge levels showed better results in health literacy. It was observed that higher levels of knowledge offset the impact of limited processing capacity, thus the performance of more knowledgeable participants were less likely to be associated with processing capacity (Thomson, Thomas, & shroyer, 2008). Knowledge makes comprehension processes more efficient and economical. Processing capacity and general knowledge were most related to S-TOFHLA performance while for the REALM, general and health knowledge were most important. It was shown clearly that general knowledge, health knowledge and processing capacity were the major causes for the variances in the two measures of health literacy. Accumulation of knowledge relevant to the text topic as a result of ageing explains the resilience of the situation model processes among older adults. The two health literacy measures tap different abilities (Luque, Castaneda, Tyson, Vargas, Proctor, & Meade, 2010). The choice of the measure to use depends on an analysis of demands imposed by the criterion task. S-TOFHLA is good at predicting how well patients perform when it comes to tasks that involve general comprehension and reasoning tasks. REALM is better at predicting performance in tasks that depend heavily on illness knowledge (Alex, Federman, Sano, Wolf, Sui, & Halm, 2009).
A study was conducted on a national sample of Taiwanese adults in 2008 to assess health literacy using the Mandarin Health Literacy Scale (MHLS). The MHLS is a reading and numeracy machine that assesses health literacy in Mandarin Chinese and Standard Chinese. An approximated 30% of the sample population taken had inadequate or marginal health literacy. Lower levels of health literacy were observed in people who were older, had poorer educational entertainment and those with lower income. It was also observed that people who lived in less populated and more rural areas had a lower level of health literacy as compared to those who lived in more populated and urban areas. It was observed that health literacy was not independently associated with healthcare utilization (wright, damme, schmitt, & meheus, 2006).
A study was done based on developing predictive models of health literacy using a nationally representative sample. Data from the 2003 national assessment of adult literacy (NAAL) was analysed to predict health literacy scores. The predictors used include; gender, age, ethnicity, poverty status, marital status and length of time spent in the United States. Lower educational attainment, ethnic minority, lower income and recent immigration to the United States were associated with lower estimated health literacy. People who were not married were also observed to have lower estimated health literacy. Race and ethnicity were observed to have a strong correlation with health literacy. This may be explained by the variance in the quality and the level of education attained generally by different races and different ethnic groups (Gutierrez, Bertozzi, Conde-Glez, & Aleman, 2006). There was no association observed between the language spoken in the home and health literacy (stu., 2009).
A study was conducted by Gutierrez et.al to investigate the risk behaviors that might lead to sexually transmitted diseases. The study was based on the assumption that adolescents are more likely to indulge in behaviors that might be considered to be risky. The survey was carried out in adolescents from poor backgrounds in more than 204 tiny urban centers within Mexico (Gutierrez, Bertozzi, Conde-Glez, & Aleman, 2006). The results of that study showed the presence of Chlamydia in nearly 8% of participants that were found to be sexually active. About 12% of the participants were positive for herpes infection. The risk behaviors identified in this study were found to be associated with other behaviors (Gutierrez, Bertozzi, Conde-Glez, & Aleman, 2006). The results of this study show that health literacy among people living in poor conditions is very low and therefore, result into certain risky behaviors.
Papiloma viral infection is the passing of the human papillomavirus from one person to another through skin-to-skin contact. The virus is normally spread through vaginal, anal or oral sex, but sexual intercourse is not necessary for infection to occur. An approximate of twelve types of human papillomavirus cause genital warts. It has been established that more than 15 types of the virus cause cancer of the anus, cervix vulva, vagina and penis. The spread of this virus can be reduced by limiting your number of sexual partners and using condoms during copulation. Health literacy on papiloma viral infection should be done to sensitize people on the spread of this virus (winer, et al., 2009).
Individuals and organizations should come together to advocate for health literacy in our society. The government should form organizations that will be responsible for developing and disseminating health and safety information that is accurate, accessible and readily usable. Changes in the healthcare system should be promoted to improve health information, communication and informed decision making on matters relating to health. Health and science information and curricula should be incorporated in the education system through the university level (amnkwah, ngwakongnwi, & quan., 2009). The government should also support and expand adult education. The government should also improve research and development activities that will help in development, implementation and evaluation of health literacy (Akoulova, tsui, irwin, damme, & aguado, 2008).
Human Papiloma Virus and Vaccination Efforts
Vaccines can be regarded as “socio-technical objects that have technical, cultural historical, and economic, geopolitical, and ethical dimensions” (Graham & Mishra, 2011, p2. Currently, there are two major vaccines available for this virus in the global market. These are Gardasil and Cervarix. The v (Protheroe, Wallace, Rowlands, & DeVoe, 2009)accines are capable of protecting against the two HPV types (HPV 16 and HPV 18). Both vaccines have been shown to potentially protect against the precancerous lesions of the cervix. Particularly, Gardasil has been shown to prevent potential precursors to anal, vulvar, vaginal and penile cancers. Scientists expect HPV vaccines to protect against HPV induced cancers of these areas as well as HPV induced oral cancers (Thomson, Thomas, & shroyer, 2008).
The Gardasil is an adjuvant vaccine that is specifically formulated for four types of the Human Papillomavirus (HPV) (lowy, solomon, hildesheim, & schiffman, 2008). The Vaccine was first licensed for use in Gabon, followed by the US, Canada and other countries. The vaccination was initially indicated for females whose age ranged from 9 to 13 and also from 14 to26 year-olds who were already sexually active (tay, ngan, chu, cheong, & tay., 2008). For older women, vaccination is usually considered depending on specific circumstances.
Cervarix was developed by GlaxoSmithKline and was available in Australia in 2007, and was used for females between the ages of 10 to 45. The vaccine was available in Europe later that year and the US in 2009. The United States Food and Drug Administration (FDA) licensed the use of Gadasil for males aged between 9 and 26 years, and was mainly indicated to prevent against the development of genital warts that result due to HP6 and 11 (Graham & Mishra, 2011). Cervarix and Gardasil are vaccines intended to offer prophylaxis to individuals suffering from type 16 and type 18 HPV. In addition, Gardasil may offer protection to HPV type 6 and type 11. This was established in studies conducted on genital warts (Akoulova, tsui, irwin, damme, & aguado, 2008).
HCV vaccines are important in the sense that they help individuals to mount a mount a strong defense. Several countries have established mechanisms to facilitate the adoption of HCV vaccines in the public domain. Many countries have rolled out programs to promote the large scale use of the vaccines in the public sector and for national immunization. However, this is not the case in developing countries, in which HPV are yet to be provided through a national immunization program (Akoulova, tsui, irwin, damme, & aguado, 2008).
The utilization of HPV vaccines in developing countries has been affected by high costs of the vaccine. Studies have shown that high costs associated with the human paipiloma virus vaccine are directly related to monopoly pricing by manufacturers who want to recoup the developmental costs. Their ability to keep their patent rights and, therefore, keep prices high is also driven by the lack of compulsory licensing that will which can stimulate the competitive development of affordable HPV vaccines (Akoulova, tsui, irwin, damme, & aguado, 2008).
According to a study conducted by Graham Mishra and Mishra, HPV immunization has the potential to provide solutions for the challenges that are faced when screening for HPV. However, there are various barriers that stand in the way and prevent implementation of necessary measures, particulalry in the developing world (cutts, et al., 2007). The lack of public awareness has made it difficult to effect both primary and secondary prevention strategies. Embarrasing situations that are often associated with STIs have affected the reception of HPV immunization. Therefore, in most cases, HPV immunization is given to healthy individuals only, while those who may require it for secondary prevention are left out. This barrier can be tackled by increased health literacy in regard to HPV vaccination. Evidence based methods should be adopted to ensure increased efforts to promote free communication are used to facilitate acceptance (Graham & Mishra, 2011).
A study conducted by shows that the commercial rhetoric associated with HPV vaccination has played a major role in the lack of frameworks to ensure proper public education on HPV, its related diseases and the prophylactic effects and limitations. Commercial activities have played a role in how the vaccine is marketed and how different stakeholders such as scientists, healthcare providers and the general publich view the vaccination of HPV (Thomson, Thomas, & shroyer, 2008). In other words, HPV vaccination has been subjected to contests whereby advertisements and push for profits have turned direction from the its public health value.
In most developing countries, the mandatory immunization against HPV has been dismissed as an unncessary effort to prevent a disease that is not transmitted causually. The immunization has also been said to be side steping the mandate of parents over their children (fisher, darrow, tranter, & williams, 2008).
A study was conducted by Murthy et.al to investigate risk factors that were associated with the development of precancerous lesions of the uterine cervix(1990). During the study, factors related to cervical carcinogenesis were followed on a prospective basis. All dysplasia cases, progressed to carcinoma in situ (Murthy, sehgal, Das, Singh, Das, & Gupta, 1990).
Health Literacy in relation to Vaccination for Papilloma virus
Human papiloma virus popularly known as HPV is a virus establishes productive infections only in the keratinocytes of the skin or the mucous membrane. Majority of the currently known HPVs cause no symptoms in most people. However, some can cause warts or veruccae. Others have led to cancers of the cervix, vulva, vagina, penis, oropharynx and anus. This however happens in rare occasions. Of late, HPV has been linked with an increased likelihood of leading to cardiovascular infections. In addition HPV 16 AND 18 infections are strongly associated with an increased chance of contracting and developing throat cancer. It is worth noting that more than thirty to forty types of HPV are typically transmitted through sexual contact. These types mainly infect the anogenital region (tay, ngan, chu, cheong, & tay., 2008). Some of the sexuaaly transmitted HPVs may lead to genital warts. Medical research has showed that persisted infection with high risk HPV types whish are different from the ones causing skin warts may lead to precancerous lesions and in turn cause invasive cancer.
A recent report by the World the World Health Organization (WHO) has HPV is the most sexually transmitted infection in the world. For example some eighty percent of the American sexually active women will have contracted at least one strain of the disease by the time they clock fifty years of age. As the disease can be transmited through sexual intercourse, engaging in protective sex can lead to a significant decrease in the number of people contracting the disease globally (winer, et al., 2009).
These two strains account for seventy percent of the cervical cancers, eighty percent of anal cancers, sixty percent of the vaginal cancers and over forty percent of vulvar cancers. Studies have also showed that the HPV strains above also cause most of HPV induced oral cancers and some other rare genital cancers. Two strains of HPV, namely HPV 6 and HPV 11 cause nearly ninety percent of the genital warts (winer, et al., 2009).
Public health officials in United States, Australia, Canada and the European region as well as the
World Health Organization (WHO) have recommended vaccination of young women worldwide against this virus. This is aimed at preventing cervical cancer and reducing the number of treatments for cervical cancer precursors. In the United States, it is estimated approximately eleven thousand cancers found annually occur in women who have never had a pap smear; a screening test used to detect potentially precancerous and cancerous processes in the endocervical canal of the female reproductive system. Also most of these women probably never had had a pap smear in the previous five years. HPV has been found to be the cause of CCN (cervical intraepithelial neoplastic) (winer, et al., 2009). CIN is a precursor to cervical cancer. It is costly and painful to treat. However, there are no reliable statistics to show how many women have been diagnosed with this infection worldwide. Since these vaccines only covers some high risk types of HPV, medical experts still recommend that women get regular Pap smear screening even after the vaccination (cutts, et al., 2007). HPV vaccination is also recommended for many males in many areas. This is aimed at protecting their partners from contracting cervical cancers. Additionally, the vaccination can protect them against anal cancer and may also prevent other (sankaranarayanan, et al., 2008).
HPV associated cancers. Gardasil is accredited for protecting males against genital warts. The United States public health officials have recommended HPV VACCINATION for males where the uptake among women has been low. Also, vaccination is recommended in populations at higher risks for HPV associated cancers. These populations include in areas where men have sex with their fellow men and those with weak immune response (Thomson, Thomas, & shroyer, 2008).
Health literacy is a term which was first introduced in the 1970s. It is of increasing importance in the public health care system and public health. Health literacy is concerned with the capacities and abilities of people to meet the ever increasing and complex health demands in the modern society (Akoulova, tsui, irwin, damme, & aguado, 2008). It means placing one’s own health and that of one’s community and family into context. It involves understanding which factors are influencing it and knowing how to address them adequately. An individual is considered to have adequate level of human literacy if he has the ability to take responsibility for one’s family health and community health in general. It is worth differentiating health literacy from general literacy (Akoulova, tsui, irwin, damme, & aguado, 2008). According to the United Nations Education, Science and Culture Organization (UNESCO) during its history in English, the word literacy mostly meant to be familiar with literature or in general terms to be well educated or well learned. The focus is furthermore broadening so that literacy is not only referring to individual transformation, but also to contextual and societal transformation in terms of linking health literacy to economic growth and socio cultural change and realities (Thomson, Thomas, & shroyer, 2008).
The same phenomena can be traced to in the development of health literacy. For some time, most emphasis was to give to health literacy as the ability to handle words and numbers in a medical context. In the recent years, the concept is broadening to also understanding health literacy as involving the simultaneous use of more complex and interconnected set of abilities such as reading and acting upon written health information, communicating needs to health professionals and understanding health instructions. American studies in the 1990s linked health literacy, showing an association between low literacy and decreased medication adherence, knowledge of disease and self-care management skills (Akoulova, tsui, irwin, damme, & aguado, 2008). A report by the Institute of Medicine indicates that nearly half of the American adult population may have difficulties in acting on health information. The finding has been referred to as the health literacy disaster. In response, measures have been taken to ensure better health communication through and established health literacy guidelines. Also a trans-disciplinary approach has been encouraged to improve health literacy. To support this approach, the American Medical Association recommends an emphasis on the following four areas of research: Health literacy screening, improving communication with low literacy patients, costs and outcomes of poor health literacy, and causal pathways of how poor literacy influences health.
The research literature and on health literacy influences has been expanded exponentially with nearly five thousand publications. The majorities of them have been published since 2005 and is evident that health literacy is being explored within different disciplines and with different approaches (scarinci, et al., 2010).
Until recently, the interest in health literacy was mainly concentrated in the United and Canada.
However, it has become more internationalized over the past decade. Although the European Union produced less than a third of the global research on health literacy between 1991 and 2005,the importance of the issue is increasingly recognized in European health policies. AS a case in point, health literacy is explicitly mentioned as an area of priority action in the European Commission’s Health Strategy 2008 – 2013. This strategy is linked to the core value of citizen empowerment, and the priority actions proposed by the European Commission include the promotion of health literacy programs for different age groups (winer, et al., 2009).
In Malaysia, cervical cancer has been identified as one of the most common cancers among women. The most underlying primary cause of this cancer is the HPV. India alone has the highest number of the estimated deaths with Asia which is equivalent to a quarter of the total worldwide deaths. In Malaysia, it constituted about twelve point nine percent of all cancers. According to the statistics from the Ministry of Health Malaysia, there was an average of about three hundred thousand hospital admissions of cervical cancer per year. Majority of the patients presented late stages of the disease. The death rate due to cervical cancer from 1996 to 2000 ranged from 0.29 5 to 0.41 %. Prevention, early diagnosis and treatment have shown to reduce mortality due to cancers caused by HPV in many countries. In Malaysia the cervical cancer screening program was introduced in 1969 to ensure early detection of cervical cancer among the target group of women aged between twenty and sixty five years. Many action plans and cancer awareness campaigns have been launched over the years. However, no significant reduction in the prevalence of cervical cancer has been note to date. The coverage and the uptake of the cervical cancer screening is considered poor as the Pap smear coverage in the country is less than two percent in the year 1992, 3.5% in 1995 and 6.2 % in 1996 (Stanley, 2010). This is as per the state regulatory approval of the statistics from the Ministry of Health in 1997. There are many of the reasons behind this poor uptake. The major one is the unawareness of the general public about the benefits of screening. In the year 2006, the Malaysian government provided a regulatory approval of the vaccine. However, there are many barriers associated with the effective implementation of these regulatory guidelines. Some of them include costs, limited vaccine availability and lack of vaccine awareness. A little is known about the level of knowledge and attitude towards HPV vaccine in Malaysian women (tay, ngan, chu, cheong, & tay., 2008). Additionally, still there is a scanty of information about the barriers of HPV prevention in this country. A recent qualitative study showed that the majority of participants were not aware of HPV and HPV prevention. It was interesting to note that only ten percent of them heard about the HPV vaccine. Most of the Malaysian citizens have not heard about the existence of HPV. This figure is even higher when it comes to those who know about the existence of its vaccine. Marital status and the level of education contributed to the level of the awareness. Only 25 % percent of the respondents knew that HPV vaccination can protect women against cervical cancer. 15 % of the respondents reported the vaccine can be offered to female children of female gender of age nine years and above. Only 18% reported that HPV vaccine requires two to three injections (Graham & Mishra, 2011).
Majority of the respondents (53%) had a positive idea about the Introduction of HPV vaccine. Some of the respondents who had a negative idea about the introduction of the vaccine were concerned about its side effects. Others were concerned about the needles while the rest were concerned about the social stigma associated with this vaccination. Other barriers that the respondents reported included:
Do not have time to take vaccination
Vaccine is expensive
Vaccine is not easily reachable
Vaccination is not needed if one is not sexually active
In Norway, about twenty percent of the women have heard about HPV vaccination. Most of the respondents were not familiar with its cost and how many injections are needed (Thomson, Thomas, & shroyer, 2008). Majority of the people reported that this vaccine is only foe women with more than one sexual partner. Similar findings also reported that many young women felt that they did not require the vaccine or would prefer to wait because they were not sexually active. The study showed the failure to educate women on the importance of vaccine before sexual exposure. Governments must make deliberate efforts to make sure that women are aware of this vaccine (Thomson, Thomas, & shroyer, 2008). They must also go a step further to ensure that this vaccine is administered to young women before they become actively engaged in sexual behaviors. A study carried out in Canada showed that most women would accept HPV vaccine if it was offered free of charge (tay, ngan, chu, cheong, & tay., 2008). The recommended three dose course costs about US$360 in Malaysia. This is unaffordable to many women especially those in the lower socio economic status. To encourage a wide coverage and uptake, the vaccine needs to be incorporated in the country’s vaccination program. On the issues of needles, mothers whose daughters who did not mind about the needles, would have their daughters vaccinated. Most of the young women disliked needles due to the pain associated with it. It would be very important to address the fear of needle pain as a part of the counseling process. Accurate, reliable and supportive information needs to be availed to the members adequately (Akoulova, tsui, irwin, damme, & aguado, 2008). Consistent findings showed that the rejection of the vaccination was largely due to the newness of the vaccine. People therefore do not have enough information regarding the safety and efficiency of the vaccines. It is highly recommended for any physician to provide information on the vaccine efficiency and the duration period. This makes the patient to make more informed choices. Higher education was associated with higher levels of HPV vaccine awareness. To address this, educational materials should be developed to provide comprehensive, detailed information about the HPV and the vaccine emphasis given to women form minority groups and those with lower levels of education. Marries status was also found to significantly affect the HPV vaccine awareness. Unmarried women consider themselves at a greater risk of getting this virus. This makes them get more interested in getting vaccination.
A study was conducted by Wight et.al on the need to promote behavior change at cultural level in rural Tanzania(2012).
In the developing nations, the public sector health system benefits from national l immunization programs in collaboration with WHO’s Expanded program on Immunization (EPI). Unfortunately, despite efforts by the policy makers and donor countries, several African countries still have minimum coverage (Thomson, Thomas, & shroyer, 2008). These low levels of awareness and immunization can be attributed to lack of inadequate funds to educate the public and implement the programs. Also, these countries had already given a priority in other diseases like malaria, polio and tetanus and there is general lack of political good will to embrace nationwide HPV vaccination campaigns. Some of the traditional African groups are likely to view the HPV vaccination with caution and other conservative groups may reject the vaccine altogether. Already, suspicion of the West led some Kano leaders in Nigeria to reject immunization against polio as they thought it would result into sterilization or it contained HIV virus. Some groups view that the vaccine may raise cases of irresponsible sexual behaviors among the teenage girls leading to low levels of awareness (tay, ngan, chu, cheong, & tay., 2008).
The developed nations have recorded a commendable progress in the awareness and the subsequent introduction of the HPV vaccination programs. Licensure and approval has been obtained in over one hundred countries. Out of these some twenty eight wealthy nations have successfully incorporated HPV vaccines in their national immunization schedules. This has been prompted by the permissiveness of sexual debut among pubertal girls and the increased rates of unprotected sex among the adolescents. These countries have increased education, advocacy, acceptance and evaluation of long term vaccine efficacy. This has led to the increased uptake of HPV vaccine. Secondary prevention of cervical cancer is well established in Europe and Scandinavia (Amnkwah, Ngwakongnwi, & Quan., 2009).
A study was conducted by Vogtmann et. Al. to establish the Knowledge of HPV among Mexican college students (2011). The student intended to establish what the findings meant for intervention programs. The data was collected from 1,0109 college students with a response of 77%. The age of the students investigated ranged from 17 to 25 years old and were from the Autonomous University of the State of Morelos in 2006 (Vogtmann, Siobon, Valdez, & ponce, 2011). The investigation was conducted using questionaires.
The results of the study showed that about 16% of students had never had of HPV. Most of these student were male with no running water at home (Vogtmann, Siobon, Valdez, & ponce, 2011).
A study was conducted by Luque et.al to identify awareness on HPV among latina immigrants and Anglo American women of Southern United States. The study was based on previous “findngs tha indicate higher cervical cancer prevalence rates among Latinas. The study used a crosssectional mixed method design and explored knowledge attitude and beliefs regarding the
HPV”(Luque, Castaneda, Tyson, Vargas, Proctor, & Meade, 2010). Data analysis was conducted using a multivariate distribution one way ANOVA tests. The results of this study showed that different cultures had the same opinion on the risk factors associated with cervical cancer (Luque, Castaneda, Tyson, Vargas, Proctor, & Meade, 2010). Other findings findings showed that Anglo American and Puerto Rican women had greater awareness on the HPV and HPV vaccination. The results suggested the need to evaluate attitudes, beliefs and knowledge in various subgroups that experience cervical cancer disparities (Luque, Castaneda, Tyson, Vargas, Proctor, & Meade, 2010).
A review was conducted by Fernandez et.al to investigate how HPV vaccination can be integrated with clinical, community and policy perspectives. This review is based on the findings of growing literature that describes associations between psychological, organizational , interpersonal, social factors that influence HPV vaccination acceptability (Fernandez, Allen, Mistry, & Kahn, 2010). This led to the establishement of an integrated model that can be employed as a tool to organize factors at multiple levels and therefore guide intevention measures and future research (Fernandez, Allen, Mistry, & Kahn, 2010).
With the proliferation of health literacy research and policy measures, it becomes clear that there is no unanimously accepted definition of health literacy concept. Moreover, dimensions of health literacy remain disputed, and attempts to operationalize the concept vary widely in scope, method and quality. As a result, it is very difficult to compare findings with regard to health literacy emerging form research in different countries. This literature review has tried to address this issue by offering a systematic of the existing definitions and concepts of health literacy as reported in the international literature. It has identified the central health literacy dimensions, the target group as well as the antecedents and the consequences. In order to develop an integrated definition and conceptual model of capturing the most comprehensive evidence based dimensions of health literacy (Akoulova, Tsui, Trwin, Damme, & Aguado, 2008). There is evidence that increased knowledge of a particular disease and its associated vaccine have proven to be extremely crucial in determining an individual’s health beliefs and practices. Raising public awareness and knowledge on HPV and HPV vaccine are important determinants of health and health promotional programs implemented by any government. This literature review has clearly showed that without clear communication on vaccines, they may have little or no impacts at all on the disease burden. It is important to raise awareness among members of the public on HPV and its links to the cervical cancer. This education should include information about safety and its benefits to prevent cervical cancer. Thus public health campaign coupled with patient education is required to increase the acceptance of HPV vaccine among the members of the public. Even though HPV vaccine has been available in Malaysia since November 2006, high price of the vaccine is still a barrier which prevents many women to be vaccinated. It is therefore important to offer the vaccine in lower price to make it affordable to many women (Koulova, Tsui, Irwin, Damme, Biellik, & Aguodo, 2008).
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