This research was a school-based study to assess whether a structured-educational intervention can improve parental awareness, knowledge, and perceptions about HPV infection, cervical cancer, and HPV vaccination as well as acceptability of HPV vaccination. Before the intervention, most of the parents had poor baseline knowledge and some negative perceptions of HPV. After the intervention, there was a significant improvement in parents’ HPV-related knowledge and perceptions as well as their intention to permit the HPV vaccine for their children.
At the baseline, we found that most of our participants had heard about STIs and cervical cancer, but less than half of them had heard about HPV infection and the vaccine. A previous qualitative study assessing parental knowledge and perceptions of HPV and cervical cancer prevention in rural Central Java, Indonesia (2015) found that most respondents have limited knowledge of HPV and the vaccine as well as the relationship between HPV and cervical cancer . Compared to a study 4-years earlier which was conducted in the same province (Yogyakarta Province) in 2013, there was almost no improvement in parental awareness of HPV vaccination (44% of our respondents compared to 47% of earliest study respondents had heard availability of the HPV vaccination), and the percentage of parents who reported their children had received the vaccine (8.0% of our respondents compare to 4.4% of earliest study respondents reported their children had received the vaccine) . Since the vaccine has not been included in Indonesia NIP then this may be the reason why the community is not very aware of the availability of the vaccine and this causes the low vaccine uptake. These findings are similar to previous studies in developing countries where HPV vaccination has not been included in their NIP [18, 21].
There were several factors related to the acceptability of HPV vaccination. From the regression analysis, we found that better knowledge and positive perceptions of the HPV vaccination were significantly associated with higher acceptability. In line with our study, previous reports have shown that parents’ knowledge about HPV was positively correlated with HPV vaccination acceptability [9, 12]. Perceived risks of HPV infection, perceived vaccine benefits, and vaccine safety were associated with the acceptability of HPV vaccination. Perceptions that their children were at greater risk of getting cancer indicated more desire to permit their children to get the HPV vaccine. Parents wanting to protect their children from cervical cancer and other HPV related diseases as the perceived benefits of HPV vaccination, had a strong relationship with the intention to vaccinate. On the other hand, parents who were not sure about HPV vaccine efficacy and afraid of any side effects which might be harmful to their children were less likely to accept the vaccine [22,23,24,25,26,27,28]. This finding emphasized the importance of interventions to modify parents’ knowledge, perceptions, and beliefs regarding HPV disease and the vaccines.
We found that besides the vaccine’s benefits and safety, free of charge, the vaccine being included in NIP, and the vaccine considered halal (permissible under Islamic Shariah Law) were important considerations for accepting the vaccine. Including HPV vaccine in the NIP and providing health insurance could eliminate the cost barriers. Because the majority of our study population is Muslim, the halal issue is an important consideration for accepting the vaccine. Previously, the non-halal status was reported as a barrier to the rotavirus vaccine acceptability in Yogyakarta, Indonesia. Engagement of religious leaders is needed to facilitate the bridge between immunization programs and the community, particularly during the introduction of a new vaccine .
Earlier studies found that parents need HPV-related information to decide whether to accept or refuse the HPV vaccination [8, 13, 30]. In line with the WHO recommendations , a systematic review of knowledge, attitudes, and barriers toward HPV vaccination in developing economic countries of South-East Asia Region emphasized the importance of educational campaigns before the vaccine is included in the NIP to improve vaccine uptake . Parents should be provided with more detailed information about HPV infection, cervical cancer, and HPV vaccination, which would help parents avoid any misunderstandings and to change parents toward a positive attitude.
Previous studies conducted in more developed countries showed the effectiveness of digital media/ website to educate parents. A randomized cluster trial, parents of 11–17 years old girls watched a digital video outlining the risks and benefits of the vaccine was conducted in Indiana, United States. It showed that adolescents whose parents watched the video had a 3-times higher odds of receiving a dose of the HPV vaccine .. Another study assessing the effect of a school-based HPV vaccination program used video presentation, and a website for girls 9–14 years old and their parents was conducted in Hongkong. The program resulted in a higher uptake of the HPV vaccine .
In developing countries such as Indonesia, which internet access is not always available, providing a more “conventional” education would be more feasible and acceptable. Our study found that a structured-education intervention using a standard PPT presentation followed by an interactive discussion focused on HPV disease and the vaccine improved parents’ knowledge, perception, and acceptability. This result emphasized the effectiveness of “conventional” educational interventions to target consumers/ parents in improving the acceptability of vaccines proven by previous studies. A hospital-based, brief, HPV-focused intervention, using a PPT presentation, improved the awareness and acceptability of HPV vaccine among rural Chinese woman’s . Another study in China assessing a short-education seminar designed for low educational level caregivers showed a remarkable improvement in vaccination knowledge . A one-hour educational presentation was effective in improving Malaysian parent’s knowledge and had an essential impact on vaccine acceptance . A school-based intervention study assessed the effect of an hour PPT presentation intervention on HPV knowledge and attitudes towards HPV and its vaccine among junior school students in Chengdu, China. The study results demonstrated the effectiveness of this intervention in improving HPV knowledge among students and increasing their willingness to be vaccinated . Even though we used a structured PowerPoint presentation, we should consider the presenter’s role in facilitating interactive discussion. Therefore, when implementing this module, we should conduct training for facilitators who will provide this intervention with skill “how to facilitate an interactive discussion”.
The structured-educational intervention conducted in our study, in the form of a presentation and interactive discussion by professional health educators, was shown to significantly improve the parents’ knowledge and perceptions about HPV. Giving educational campaigns could increase parental knowledge and perceptions about HPV, concurrently with physician recommendations and nationally funded vaccination programs [21, 28]. A systematic scoping review (2019) regarding communication concerning HPV vaccinations in low and middle-income countries found that physicians were important components to deliver information about HPV and give parents a recommendation to get HPV vaccination for their children . Another systematic review conducted by Radisic et al. (2017) found that uptake of HPV vaccination may be facilitated by encouraging health care provider endorsement .
This research has some limitations. This one group pre-test -post-test design study without a control group did not allow us to confirm any causal relations between the intervention and outcomes. A pre- and post-test without follow-up could not determine the long-term effectiveness of the educational intervention on HPV vaccination acceptability. Further study, a randomized control trial with longer follow-up are needed to evaluate the long-term and actual effectiveness of improving parents’ knowledge and perceptions about the HPV vaccination as well as the vaccine acceptability. The strength of this study is that it assessed the effectiveness of an education intervention before the implementation of the HPV vaccination demonstration program, which included a representative sample of parents in Kulon Progo, a rural District. The results of this study can provide important evidence to the policy-makers about the importance of health education.