Извадок KNOWLEDGE ABOUT HUMAN PAPILLOMAVIRUS AND ASSOCIATED FACTORS AMONG POPULATION IN THE REPUBLIC OF KOSOVA

Цитирање: Косуми Е, Исјановски В, Спасовски М. Знаења за хуман папилома вирус и фактори поврзани со него кај населението на Косово. Арх Ј Здравје 2022;14(2) doi.org/10.3889/aph.2022.6059 Online First Клучни зборови: хуман папиломавирус, рак, Република Косово, знаење *Кореспонденција: Ернад Косуми, Универзитетски клинички центар на Косово, Оддел за гинекологија и акушерство, Приштина, Косово. E-mail: ernadkosumi@gmail.com Примено: 28-јан-2022; Ревидирано: 30-јун-2022; Прифатено: 5-јул-2022; Објавено: 10-јул-2022 Печатарски права: ©2022 2022 Ернад Косуми, Виктор Исјановски, Моме Спасовски. Оваа статија е со отворен пристап дистрибуирана под условите на нелокализирана лиценца, која овозможува неограничена употреба, дистрибуција и репродукција на било кој медиум, доколку се цитираат оригиналниот(ите) автор(и) и изворот.


Introduction
Human papillomaviruses (HPVs) are an essential group of viruses affecting the cutaneous and mucosal epithelia. HPVs trigger diseases related to high morbidity and mortality rates, involving benign lesions and cancer 1 .
Above 70% of sexually active women and men will be infectedat some pointin their lives, and several may yet be infected in more than one circumstance 2 .
The projected incidence of HPV contagion is high, with 14 million people affected yearly and 79 million people with predominant infection 3 . HPV is linked with numerous cancer types in both men and women. Amongst women, in 2012, HPV was related with 74% of cancer cases, 70% of which were cervical cancer 4 .
There is a need for evidence about the HPV registry and cervical cancer in Kosova; however, a survey led by Zejnullahu V. in 2016 in Kosova presented a high HPV frequency, estimated up to 50.93% (109 samples) out of 214 cervical samples 5 .
Papillomaviridae family consists of more than 200 varieties of HPV, which are categorized into five classes: Alphapapillomavirus, Betapapillomavirus, Gammapapillomavirus Mupapapillomavirus, and Nupapapillomavirus 6 . All the classes are responsible for the numerous kinds of HPV-associated cancers.
Moreover, based on oncogenicity, the mucosal type (alpha) is divided into two subtypes which are low risk (LR), HPV 6, and HPV 11, which are recognized to cause benign genital warts, and high-risk (HR) cervical cancer 7 . HPV 6 and HPV 11 are also recog-nized to cause respiratory papillomatosis, predominantly in children 8 .
High-risk papillomavirus is responsiblefor causing cancer associated with the cervix, vulva, vagina, anus, penis, and oropharynx 9 . Most infections are benign, leading to lesions such as cutaneous warts on the hands, feet, and anogenital zones. Only a small number of diseases with specific types of HPV can last and progress to cancer, such as oropharyngeal, cervical, vulvar, vaginal, and penile cancers 10 .
Around 80% of sexually active women acquire HPV infection, while most of them are asymptomatic with the immune system-mediated clearance of the infection within 6-12 months 11 .
Cervical cancer is undoubtedly the most widespread HPV-associated disease 10 . Almost all cases of cervical cancer are a result of a continued or chronic HPV infection. The fourth most recurrent cancer in women globally is cervical cancer, and it accounts for approximately 528,000 new cases per year 2 .
Nearly 85% of the worldwide burden happens in the less developed countries, accounting for approximately 12% of all female malignancies. In 2012, an estimated 266,000 deaths were credited to cervical cancer, accounting for 7.5% of all female cancer deaths, with closely 90% of these deaths happening in the less developed countries 2 .
In the developing regions, cervical cancer may cover up to 25% of all female cancer cases12 and is only led by breast cancer as the most frequent cause of cancer deaths in women globally 13 .
Statistics on cancer percentages in Kosovo are unavailable as a national cancer office is in the procedure of re-launching, and recording procedures have yet to become official. However, incidence information presented for 2013 reported 224 breast and 27 cervical cancer cases. A survey led by Knowles  HPV may be transmitted throughout perinatal (during birth from mother to child) 16 , genital infections (genitals, anus, or mouth of an affected sexual partner) 17 , hands, shared object, blood, surgery (during laser ablation of a condyloma (wart) or electrocautery) 18 HPV does not transmit through ordinary stuff like toilet seats 16 , although the types that cause warts may transmit through surfaces such as floors 19 .
This survey aimed to investigate the level of knowledge regarding human papillomavirus (HPV) infections and HPV-associated diseases among residents in the Republic of Kosova and to discover the relationship between these factors.

Material and methods
A cross-sectional survey was performed by investigating the knowl-edge concerning HPV infection in the population aged 18 to 35+ years. The study was conducted in the period from June 2021 -August 2021.
The sample was obtained based on convenient selection, and included 500 participants.
Information from participants in the study group was gathered through interviews, using a predesigned questionnaire, online version: distribution via social media, paper version: distribution during student conferences, lectures, and distribution in libraries. Survey clarification was available whenever it was necessary. Each part of the questionnaire offers the objectives of the survey and the measures for protecting anonymity. Participation was voluntary, and all information was handled confidentially.
Criterion for inclusion was the age of the participants (from 18 to 35+ years). This age group is selected because it is the part of the population that is most vulnerable to HPV infection and HPV-associated diseases and a crucial part of the society that decides and will decide to vaccinate their children against HPV. The latter comes up from the fact that people subject to manda-toryHPV vaccination are 12-year-old girls who do not decide for themselves and whose vaccination needs their parents' permission.
Given that a validated questionnaire is not available in the Republic of Kosova, we remodelled a series of questions based on Knowledge, Attitude and Practice (KAP) survey in settings with a related socio-cultural situation to the Republic of Kosova to investigate KAP about HPV. We also conducted a pilot study to test the validity and trustworthiness of the questionnaire. As reported by World Health Organization, KAP survey data can recognize how knowledge differences, cultural beliefs, or behavioral patterns may influence understanding and action and cause struggles or create obstacles for HPV vaccination.
The design of the questionnaire was guided by the survey and the literature review of the knowledge regarding HPV.
The questionnaire was composed of 2 groups. The first group of questions gives information on the sociodemographic characteristics of the respondents, including age, gender, location (urban or rural), level of education, occupation, marital status, and sexual activity of respondents. The second group refers to the respondents' knowledge about HPV and the source of transmission of HPV.
The pilot questionnaire was sent to 50 respondents, and according to the perceived response, corrections and adjustments were made to the target population and the survey's objectives.
The participation was voluntary; all information was handled in confidence. The participants were provided a detailed clarification of the reasons for the survey and were notified of the actions being taken to protect their anonymity. The questionnaire was anonymous, and participants were free to end the participation at any time, without finishing the questionnaire.
A password-protected computer was used to keep the excel sheets, and a secure lockable cabinet was also used to save filled questionnaires.

Results
The study for knowledge on human papillomavirus and associated factors included 500 respondents, citizens of the Republic of Kosova.
Sociodemographic data of the respondents Prevalence of adult groups in the study ranged from 21.0% (age group from 18 to 21 years) to 18.8% (age group from 34+ years) ( Table 1 and Figure1a). The percentage difference wasstatistically insignificant-forp<0.05.
A larger percentage of respondents were from females 60.0%, and 40.0% were males (Table 1b).
Approximately half of the respondents -44.8% were employed, 33.4% were students, and 14.6% were unemployed, 3.0% were still in school and 4.2% had other kind of occupational status (Table1).  To the question Can HPV heal by itself, the largest number of respondents, 60.8% (n=304), responded I do not know, 25.4% (n=127) of the respondents gave false answer, 12.8% (n= 64) gave true answer and 1.0% (n=5) of the respondents did not answer. The percentage difference between the unknown answer versus the other modes of choice was statistically significant for p<0.05 (Differential test P= 0.0000) ( Table 5).    26 . The deficit knowledge of HPV and the fact that 75.4% of participants did not use a condom at their last intercourse is considered to be severe as HPV is the most common sexually transmitted infection 28 , and cervical cancer is caused by HPV 28 . It is fundamental to broaden the knowledge of HPV so that people will understand how to avoid the infection from ever happening and so that young men and women will have protected sexual behavior.

Age -Years
This survey has some possible limitations. Firstly, the survey questions were explored by a cross-sectional study design. Such a strategy prevents the determination of fundamental associations among various factors and results. Secondly, evidence was collected by self-reported questionnaire, and hence, several answers might have described incorrect data. Apart from this criticism, the privacy of the survey might have lowered the deviation in the answers. This research, though, presents significant strengths: firstly, it delivers evidence from a vast number of participants, and this permits investigation of extremely weak relations among variables; secondly, the information was complete; thirdly, the participation percentage was very high, perhaps indicating increased curiosity for this study.

Conclusion
A significant number of the population contributing to this survey had a poor knowledge about HPV. It is crucial to improve the inadequate knowledge about HPV among the people in the Republic of Kosova to change behavior in order to be vaccinated against HPV. As a footstep towards getting a lower rate of cervical cancer and reducing the number of deaths because of the disease, serious efforts in health education are required. The preventive work needs upgrading. To do so, it could be significant to assess which factors affect the knowledge so that young women and all adolescents will get pushed to use protective measures against cervical cancer and have protected sexual behavior.