A Literature Review regarding Cervical Cancer Prevention Targeting Junior and Senior High School Students

Objective: To understand the state of education for the prevention of cervical cancer and trends in research. The subject of cervical cancer prevention will be examined. Method: Articles from the ICHUSHI Web version 5, CiNii, and PubMed databases for the period from 2009-2019 were used. Search terms used were cervical cancer, HPV/human papillomavirus, prevention, public awareness, and education. Results: 17 articles (9 Japanese and 8 English) were analyzed. The majority of students had heard of cervical cancer but did not know of the link between it and HPV. Vaccinated individuals were significantly more likely to have deeper knowledge regarding cervical cancer and HPV. Various factors affect the vaccination rate. These include knowledge of HPV and cervical cancer, age, ethnicity, the organization or location which administers the vaccine, how to breach the subject, finances, and the opinions of friends and family. In particular, consultations with parents lead to mothers recognizing the importance of the vaccine. By way of educational intervention, opinions have grown more positive about advancing awareness, being vaccinated, and having cervical cancer screenings for the future. Conclusion: The prevention of cervical cancer requires support and fostering the judgement based on sufficient awareness and adequate education. What we need is educational intervention rooted firmly in the current societal climate aimed not only at students, but at their parents as well.

an increase in sexual activity among young people. Furthermore, the proliferation of HPV, which is a risk factor for cervical cancer, has been lowering the age of patients in which pathological changes to the cervix are found.
In 2016, recorded deaths due to cervical cancer increased to 2710 cases. Of special note is the rate of cervical cancer in women aged 15 -30, which has increased by 5.6 times in the past 30 years [1]. Between the ages of 15 -24, the rate has increased by 24.1 times [1]. The proliferation of HPV has brought on an increase in cervical cancer cases and a lowering trend in the age of patients, becoming a fertility issue.
As a prevention measure against cervical cancer, Japan has established a free vaccination period for students from the first year of junior high school to the first year of high school, as well as lowered the age in which free cervical cancer screening vouchers are distributed to age 20 [2]. However, rates of treatment are low when compared to those abroad, at 0.3% for HPV vaccine and 42.3% for cervical cancer screenings in 2016 [1] [3]. In light of this situation, there is concern that the problem of cervical cancer will continue to grow. Prevention of cervical cancer is an important factor in lifelong health for our youth which can help them to protect their reproductive health and avoid life-threatening conditions.
Research on HPV vaccination and educational resources concerning cervical cancer mainly focuses on college students, adult women, and parents. However, the increase of cervical cancer cases in Japanese women in their 20s demonstrates the need for investigation into the situation regarding preventative measures in junior high school students. As such, we have conducted a literature search to understand the state of cervical cancer prevention education and trends in research in order to prepare fundamental educational materials for the future.

Method
Searches were performed on the ICHUSHI Web ver 5, CiNii, and PubMed data- from PubMed. After excluding duplicate results, setting the criteria to research targeting junior high school students, senior high school students, and adolescents from academic journals 17 entries (9 Japanese language entries and 8 English language entries) were selected (Table 1).

Summary of Target Literature
Because the subject of this research was junior high and high school students, all   [20] for HPV. Awareness among female students was significantly higher than male students, and that of high school students higher than that of junior high school students [12]. In a survey of all 17-and

Awareness and Knowledge of Cervical Cancer/HPV
18-year-olds in Greece, no differences were found based on location (urban, T. Nakamura, A. Sasaki Assess education before and after a cervical cancer education program was initiated in school. Before the program, HPV vaccine acceptance was favorable but relevant knowledge was low. After the program, participants had greater knowledge and a more positive attitude, with more girls anticipating family (41.6% before vs. 58.9% after) and peer support (32.8% before vs. 56.9% after).
Mathur et al.

USA
Quantitative Survey 170 female high school students, grades 9 -12 Study the vaccination decision-making process and predictive factors for vaccination.
Overall, 48.4% participated in the vaccination decision making and 37.8% were vaccinated, but there were significant vaccine-related knowledge gaps. Vaccination was significantly associated with older age, vaccine information sources, and higher vaccine-related knowledge, but not with estimates of risk of HPV-related diseases, religion, or frequency of health care visits.
Wong et al.

USA
Quantitative Data Analysis 2205 girls aged 9 -17 Survey 1 -2 years after the HPV vaccine was approved aiming to understand sociodemographic behaviors, and why parents refuse to allow girls to be vaccinated.
We observed increased vaccine uptake with increased age. There were no differences in HPV vaccine initiation dependent on race/ethnicity. Costs were cited as the main reason not to vaccinate daughters, and they said they would get the vaccine if it were free or provided at a much lower cost. More than 60% of the participants could not answer correctly neither about HPV infection and cervical cancer frequency in sexually active women, nor about protection methods against HPV and cervical cancer. The low vaccination coverage may be due to lack of information and awareness of the adolescents and their parents. Study the change in female high school student's knowledge and awareness before and after participating in an educational course about cervical cancer prevention.
Students who participated in educational programs showed increased scores on a knowledge test about cervical cancer, HPV, and cervical cancer screenings. Students showed increased interest in preventative care. The percentage of students who expressed an intention to start screening when they turned 20 increased from 13.2% to 49.5%. suburban, rural) or religion [19]. Regarding high school students' knowledge of STIs, recognition was lower than that of AIDs (77.8%) and genital herpes (75.5%) [12]. However, among female high school students in the United States, 89.8% of vaccinated students and 7.04% of non-vaccinated students knew of the link between HPV and cervical cancer [5]. Knowledge pertaining to cervical  [20]. In Japan, in a comparison of students' knowledge before and after a sex education course targeted at first-year high school students, participants showed a greater knowledge of STIs and more appropriate perceptions of sex [15]. In Japan as well as other countries, the content of these courses and incentive programs was knowledge, causes, and symptoms of cervical can-

The State of HPV Vaccination
In Japan and the United States, the percentage of students vaccinated was 25

Determining Factors in Subjects' Intention to Get the HPV Vaccine
The determining factors of intention concerning the HPV vaccine included knowledge of cervical cancer, aggressiveness toward disease prevention, fear of cervical cancer, awareness of the possibility of contracting cervical cancer, and Cervical cancer prevention programs targeting female high school students increased the percentage of students who intended to received screenings in the future from 13.2% to 49.5% [20]. In Hong Kong as well, following an educational program for female junior high school students, students' attitudes toward the HPV vaccine improved and students intending to be vaccinated increased by 11.3% (from 74.9% to 86.2%) [4]. In an American survey, the determining fac-

Study
Both the primary prevention method of vaccination and the secondary prevention method of screening are vital to the cervical cancer prevention strategy. Because the target of study was junior high and high school students, the focus was on the primary prevention method of HPV vaccination, while the topic of the secondary prevention method of cervical cancer screenings was limited to whether students had an intention to be screened in the future.
While awareness of cervical cancer among female junior high and high school students was as high at over 70%, awareness of the link between HPV and cer-  [6]. Because the source of information for over half of junior and senior high school students was their parents or grandparents, it can be said that the role of the household in passing on this information is important. If parents/guardians are able to understand and take action, the educational responsibility is born by the household and leads to preventative action.
In the majority of Western countries, vaccinations for girls around age 12 were covered by public expenses. In addition, the United States and some other countries offered the vaccine to girls starting in the latter half of their teens, when many are likely to have sexual experiences, as well as to women in their 20 s, through a fixed-time public subsidy until the vaccination rate had increased.
Countries such as Australia and Canada which offered the HPV vaccine in national programs show a decrease in HPV cases and precancerous lesions among the vaccinated generation [24]. On the other hand, the vaccination rate in Japan has dropped dramatically after active efforts to promote the vaccine ceased in 2013 due to post-vaccination side effects [25]. Side effects included pain at the injection site, redness, swelling, etc. However, these side effects are not by any means unique to the HPV vaccine. Improving vaccination rates requires not only the students' awareness, but parents' support and consent. For this reason, providing correct and trustworthy information is vital.

Conclusions
The prevention of cervical cancer depends on the acquisition of knowledge, suitable education, and support so that informed judgements can be made. It is necessary to provide that information and opportunity. The task at hand is an approach which considers societal trends aimed at not only the patients concerned but also their parents.
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