Influence of online education programmes on parents' knowledge regarding human papilloma virus vaccination

CT Abra Pearl; M Navaneetha; S Malarvilizhi; K Mony; R Chinnadurai

doi:10.4103/ijcn.ijcn_37_22

ORIGINAL ARTICLE

Year : 2022 | Volume : 23 | Issue : 2 | Page : 164-171

Influence of online education programmes on parents' knowledge regarding human papilloma virus vaccination

CT Abra Pearl¹, M Navaneetha², S Malarvilizhi³, K Mony⁴, R Chinnadurai⁵
¹ PhD (N) Scholar, College of Nursing, Puducherry, India
² HOD, Community Health Nursing Department, College of Nursing, Puducherry, India
³ Assistant Registrar, College of Nursing, Puducherry, India
⁴ Principal, College of Nursing, Pondicherry Institute of Medical Sciences, Puducherry, India
⁵ Statistician, Padmashree Group of Institutions, Puducherry, India

Date of Submission	13-Apr-2022
Date of Decision	19-Oct-2022
Date of Acceptance	20-Oct-2022
Date of Web Publication	24-Jan-2023

Correspondence Address:
Dr. M Navaneetha
Department of Community Health Nursing, College of Nursing, Pondicherry Institute of Medical Sciences, Ganapathichettikulam, Kalapet, Puducherry - 605 014
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijcn.ijcn_37_22

Abstract

Cancer ranks as a leading cause of death and an important barrier to increasing life expectancy in every country of the world. Human papilloma virus (HPV) infection is identified as a preventable cause of genital cancer. HPV vaccination for adolescents helps in prevention of HPV infection, but vaccine uptake is poor due to lack of knowledge amongst parents. The objective is to evaluate the effectiveness of online education programme regarding HPV vaccination on the knowledge of parents of school-going adolescents. Applying the conceptual framework developed based on King's goal attainment theory, an experimental study was conducted amongst a sample of 360 parents. Samples were selected in three groups and were given online education on HPV vaccination using three different methods, namely lecture, short film and self-learning booklet. Pre- and post-intervention knowledge was assessed with a structured questionnaire. The mean score in pre-test for the three groups was 4.95 (standard deviation [SD] = 4.17), 6.33 (SD = 4.76) and 5.73 (SD = 4.91) which increased to 14.27 (SD = 4.68), 17.45 (SD = 4.14) and 12.04 (SD = 3.47), respectively, in the post-test which was significant at P < 0.001. All the three methods of education were effective in improving the knowledge. The maximum increase was seen in Group 2 educated using the short film. The conceptual model developed based on King's goal attainment theory was an excellent guide in the conduction of the study. All three methods of online education programmes were effective in influencing the parent's knowledge regarding HPV vaccination, and the short film had a better effect compared to the lecture and self-learning booklet.

Keywords: Adolescents, human papilloma virus vaccination, King's goal attainment theory, lecture, self-learning booklet, short film

How to cite this article:
Abra Pearl C T, Navaneetha M, Malarvilizhi S, Mony K, Chinnadurai R. Influence of online education programmes on parents' knowledge regarding human papilloma virus vaccination. Indian J Cont Nsg Edn 2022;23:164-71

How to cite this URL:
Abra Pearl C T, Navaneetha M, Malarvilizhi S, Mony K, Chinnadurai R. Influence of online education programmes on parents' knowledge regarding human papilloma virus vaccination. Indian J Cont Nsg Edn [serial online] 2022 [cited 2023 May 31];23:164-71. Available from: https://www.ijcne.org/text.asp?2022/23/2/164/368423

Introduction

Health of individuals can be affected in many ways such as lifestyle, habits, heredity and environment. One such factor that causes diseases is human papilloma virus (HPV) infection. HPV infection is caused by a DNA virus which belongs to the Papillomaviridae family.^[1] It is the most common sexually transmitted infection in the world comprising a group of more than 200 related viruses, some of which are spread through vaginal, anal or oral sex. Many HPV infections do not cause any symptoms and 90% resolve spontaneously within 2 years. There are two groups of HPV. The low-risk type mostly does not cause any disease but occasionally can cause warts around the anogenital region and oropharyngeal region. The high-risk type of HPV can cause several types of cancers, of which HPV 16 and 18 are the most common.^[2]

Men and women can get cancer of the oropharyngeal region and anorectal region caused by infection with HPV. Men can get penile cancer. In women, HPV infections can cause cervical, vaginal and vulval cancers.^[2] Approximately 70% of cervical cancers are caused by HPV type 16 or 18.^[3] Approximately 80%–90% of anal cancers are caused by either HPV 16 or HPV 18.^[4] At least 70% of vulvar cancers are HPV related.^[2] It is found that 60% of penile cancers,^[5] 75% of vaginal cancers^[6] and urethral and head-and-neck cancers^[7] contain carcinogenic HPV types. Almost 90% of anogenital warts are caused by HPV type 6 or 11;^[8] HPV 6 and 11 have been reported to cause papillomas of the larynx, oesophagus and bronchi which may transform into carcinomas later.^[9] The Centers for Disease Control and Prevention estimates that in the United States, about 45,300 new cases of cancer in different organs report the presence of HPV and about 35,900 of these cancers are caused by HPV.^[10]

Globally, cervical cancer is the third leading cancer in women in terms of new cases per year.^[11] In the year 2020, there were 604,127 new cases of cervical cancer diagnosed worldwide and there was a reported mortality of 341,831 women due to cervical cancer. In developing countries, cervical cancer is the most common cancer in women. Of these global numbers, 58.2% of new cases, corresponding to a number of 351,720 new cases, were from the Asian region. A huge number of deaths 199,902 cases which accounts for 58.5% of mortality occurred in the Asian region.^[12] In India, there are 432.2 million women aged 15 years and older who are at the risk of developing cancer.^[13] According to the International Agency for Research on Cancer, the estimated number of new cases of cancer in India, including both the sexes, is 1.32 million, of which 6,78,000 cases are cancers diagnosed in women. The estimated number of deaths due to cervical cancer in India can be as high as 125,000 in 2040.^[14] The 5-year relative survival rate in India is much lower than the other Asian countries corresponding to 46% falling within a range of 34%–60%.^[15] This is because more than 80% of the cervical cancer cases are diagnosed at advanced stages.^[16] Chennai, in Tamil Nadu, ranks second amongst the metros to have the highest incidence of cervical cancer. Reportedly, 17 out of 1 lakh women suffer from cervical cancer.^[17]

HPV infection, a cause for cancer, can be prevented by taking HPV vaccination. At present, there are two vaccines licensed to be used in India. Three HPV vaccines—9-valent HPV vaccine (Gardasil 9, 9vHPV), quadrivalent HPV vaccine (Gardasil, 4vHPV), and bivalent HPV vaccine (Cervarix, 2vHPV). All three HPV vaccines protect against HPV types 16 and 18 that cause most HPV cancers. Gardasil-9 (9vHPV) vaccine protects against nine HPV types (6, 11, 16, 18, 31, 33, 45, 52, and 58). The World Health Organization's (WHO) position paper on HPV vaccination 2017 states that bivalent (Cervarix), quadrivalent (Gardasil) and nonovalent (Gardsail9) vaccines offer comparable immunogenicity, efficacy and effectiveness for the prevention of cervical cancer which is mainly caused by HPV types 16 and 18. The safety profiles of all the three vaccines are excellent.^[18]

The WHO strongly recommends that HPV vaccination should be given to all girls between the ages of 9 and 14 years. This is the target age group. Vaccination should be completed before they become sexually active.^[18] Although there is licensure of vaccine in over 129 countries and 71 countries include them in their national immunisation programmes,^[19] the current estimates state that vaccination has been done only to <4% of eligible women.^[20] It is also seen that most of the women who are vaccinated are from the high-income countries, but the mortality due to cervical cancer is mostly seen in developing countries where women remain unprotected.^[21] The vaccination coverage in India at present is not known. Awareness and health-seeking practices are reported to be poor in many developing countries, including India, necessitating the need for proper awareness and vaccination programme.^[22]

Parents/caregivers of adolescents must be educated regarding HPV vaccination before offering this chemoprophylaxis against cervical cancer.^[23] Educating the parents of girls before the vaccination is feasible and is a well-accepted practice in the community.^[24] Parents can be educated in various settings such as community centres, places of worship and schools, at sports centres, on local health awareness days or in the context of a screening campaign. School is a way of reaching the parents. In Tamil Nadu, the literacy rate is 80.1% as per the 2011 census report. The literacy rate in Dindigul district is 76.6%.^[25] As the dropout rate is less and many students continue their education at least up to the secondary school level, it was found that school would be a good portal to reach out to the parents. Basing the education at the school and integrating them through school-based approach helps to reach the target groups systematically.

Considering these facts, the researchers prepared and validated an education programme for parents of adolescents and tested its effect. Owing to the COVID pandemic, the education programme was given online. Three different methods of education, namely lecture, short film screening and sharing self-learning booklet, were used for three different groups and their effect was studied. Lecture, which is a traditional and time-tested method, was used for one group of parents to provide information on HPV vaccination using PowerPoint presentation as the audiovisual aid. Short film appeals to the different senses of the individual making them receptive to the information provided. Hence, it was chosen as a method of education. Self-learning booklet can be distributed to a larger group in the community and can be saved by the individuals for further reference. Hence, the researchers selected it as a method of education. Similar methods of education have been used in other countries for educating parents. The researchers sought to assess the effect of the online education programme using these methods in the Indian context. As nursing theories provide the necessary conceptual framework to guide the research process, the researchers applied King's goal attainment theory to streamline the research process.

Objectives

To assess the existing level of knowledge of the parents of adolescents on HPV vaccination in the three groups of the study
To evaluate the effect of online education programme on knowledge of the parents of adolescents regarding HPV vaccination using lecture, short film and self-learning booklet
To compare the effect of the three methods of online education programmes on the knowledge of the parents of adolescents regarding HPV vaccination.

Hypotheses

There will be a significant difference between the pre- and post-test levels of knowledge of the parents of adolescents on HPV vaccination in the three interventional groups
There will be a significant difference between the post-test levels of knowledge of the parents of adolescents exposed to different methods of school-based education programmes on HPV vaccination amongst the three interventional groups.

Conceptual framework

Theory application

The investigators adapted King's goal attainment theory as a basis for the study and development of conceptual framework. Nursing as defined by Imogene King is a process of human interactions between the nurse and the client whereby each perceives the other and the situation through communications. They set goals, explore means and agree on means to achieve the goals. There are six major concepts of the phenomenon applied for the conceptual framework.^[26]

Perception refers to people's representation of reality. In this study, the investigator's perception is that parents of adolescents may have some knowledge on HPV vaccination which may be inadequate. The parents of adolescents perceive the need to gain knowledge on HPV vaccination
Judgment – The investigator judged that the education programme can enhance the knowledge of parents on HPV vaccination. The parents judge that utilisation of the education programme can enhance their knowledge on HPV vaccination.
Action – The investigator is ready to implement the education programme. The parents are ready to gain knowledge, willing to learn and to participate in the study
Reaction – The investigator and parents set mutual goals. The investigator identifies the existing level of knowledge by conducting pre-test.
Interaction is the verbal and non-verbal behaviour of individual, environment and between two or more individuals with a purpose to achieve the goal. The investigator interacts with the parents by providing the education programme on HPV vaccination. For the parents in Group 1, lecture method is used. For the parents in Group 2, short film is used, and for parents in Group 3, self-learning booklet is used
Transaction refers to an observable, purposeful behaviour of the individual's interaction with the environment to achieve the desired goal. The investigator analyses the level of knowledge after administration of the education programme. If adequate knowledge is seen (positive outcome), the method that is best suited needs to be enhanced further. If inadequate knowledge is seen (negative outcome), the educational programme needs to be modified and reassessed.

The conceptual framework is depicted in [Figure 1]. Based on the framework, the investigators progressed with the study.

Figure 1: Conceptual framework based on King's goal attainment theory

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Methods

Quantitative research approach with three-group experimental pre- and post-test design was used in the study. An education programme on HPV vaccination was prepared and validated by subject experts. To identify the feasibility of incorporating the education programme as a part of the school health education, three different methods of education, namely lecture, short film screening and sharing of self-learning booklet, were used and tested. Initially, the study was planned to be conducted in the school premises during the open day. However, due to the lockdown and closure of the schools during the COVID pandemic, online mode was used. The online education programmes were the independent variables. Knowledge of parents of adolescents on HPV vaccination was the dependent variable. The setting of the study selected was three higher secondary schools in Oddanchatram taluk, Dindigul district, Tamil Nadu. Parents of the adolescents studying in 7^th, 8^th and 9^th standard of school education were the study population. Power analysis was done based on the pilot study findings, and a sample size of 360 was calculated. A total of 120 in each group were taken with a power of 90% and a significance level of 5%. Each school was assigned to a group of the study and was administered with a specific method of online education. Multistage simple random sampling by lottery method was used to select the samples. In Stage 1, the schools were selected. Two sections from each class, 7^th, 8^th and 9^th standard were selected in Stage 2. In Stage 3, 20 students from each class were selected and their parents were enrolled in the study if they fulfil the sampling criteria. Willing parents who can read and understand Tamil and can handle smartphone were included in the study. Samples that were not willing were replaced using lottery method. Parents were contacted through the class teachers after obtaining permission from the school management.

Instruments

Data collection was done with a validated structured tool having two sections. Section A consisted of information regarding socio-demographic details of the participants such as gender, parent participating in the study, family type, religion, area of residence, education status of father and mother, occupation of father and mother, monthly income of family, exposure to information about HPV vaccination and vaccination status of the adolescent. Information on the knowledge of parents on HPV infection and vaccination were collected in Section B using a structured questionnaire with 25 multiple-choice questions having a single right answer. The questions covered the knowledge aspects of HPV infection, the diseases it causes, vaccination available, vaccination schedule and the side effects of vaccination. Each right answer was scored 1 and the wrong answer was scored 0. The total score was 25. The level of knowledge was then graded when >75% as good knowledge, 50%–74% as fair knowledge and <49% as poor knowledge. The assessment tool was validated by subject experts. Reliability of the tool was established by using test–retest method and the r = 0.969. Google Forms was used to collect pre- and post-test data. The link was sent to the WhatsApp number of the samples, and they were asked to give honest answers to the questions.

The intervention package consisted of the education programme with information on HPV infection, its causes and mode of transmission, signs and symptoms, diseases caused, vaccine available for prevention, advantages, details of vaccination and its side effects. The participants in each group were taught the same information using different methodologies of teaching. For Group 1, the participants were given a lecture with PowerPoint presentation by the principal investigator through Zoom platform. A total of five small-group sessions were planned, and the parents were asked to select their convenient time to attend the lecture. A short film was taken by the investigator with the help of the community health department staff of the hospital. The difficulties faced by the family with a patient with cancer and the fear about cancer were depicted in the film. The investigator took the role of the community health nurse, who explains in detail about HPV and its vaccination. The film was validated by experts. For the second interventional group, this short film was screened through the Google Meet platform. The parents were given eight different time slots for the meeting, and as per their convenience (15–20 parents in each session), they participated in the online meeting where the short film was screened followed by discussion. For the third interventional group, a colourful pdf document containing the information on HPV and its vaccination in Tamil was distributed through WhatsApp after completion of the pre-test. Reminders were sent every alternative day to encourage the parents to read the booklet. The same information about HPV and its vaccination was shared to all the three groups. After an interval of 1 week of administering the interventional package, post-test was done using Google Forms.

Analysis

The data were collected, coded, checked, entered into MS Excel and analysed using statistical software. The socio-demographic variables were expressed in terms of frequency and percentage. Comparison of pre- and post-test scores for knowledge within the group was done using parametric test for paired outcomes (t-test). Comparison of pre- and post-test scores between the groups was done using one-way analysis of variance (ANOVA). A P = 0.05 was considered to be statistically significant.

Ethical consideration

The study was approved by the Institutional Review Board of Pondicherry Institute of Medical Sciences (Approval number: IRB–PIMS/Ph. D. [N]/2018/25). Formal permission was obtained from the school management to reach the parents of the adolescents through the school. Informed consent was obtained from each subject through Google Forms before commencement of the study. Privacy and confidentiality were maintained throughout the study.

Results

Socio-demographic variables

Amongst the selected participants, most of them were mothers of the adolescent who lived in nuclear families. Majority of the parents were Hindus by religion, and a large number of them lived in rural area. Most parents were not educated in healthcare-related courses. Amongst the fathers, only 8 (6.7%) in Group 1, 3 (2.5%) in Group 2 and 7 (5.8%) in Group 3 were educated in healthcare-related education. Amongst the mothers, 4 (3.3%) in Group 1, 13 (10.8%) in Group 2 and 8 (6.7%) in Group 3 were educated in healthcare-related education. Majority of the fathers were non-healthcare workers whereas most of the mothers were unemployed. The monthly income of most families was less than Rs. 15,000/-, but they had a smartphone with internet connectivity. Of all the subjects, 28.3% in Group 1, 34.2% in Group 2 and 25% in Group 3 said that they have not heard about HPV vaccination and most of them reported that their child is not vaccinated against HPV [Table 1].

Table 1: Frequency and percentage distribution of the parents of adolescents as per the demographic variables (n=120)

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Effect of school-based education programme

[Table 2] depicts the distribution of parents of adolescents according to the level of knowledge regarding HPV vaccination amongst the three groups in pre-test and post-test. Chi-square test was performed, and in the pre-test, the Chi-square value was 6.022, with P = 0.198 which was more than 0.05. This was not significant, and hence, the three groups were found to be homogenous initially. However, the distribution of parents according to the level of knowledge in the post-test reveals a significant association (P < 0.001) with the groups receiving different methods of teaching. Group 2 who had the education with the short film reported a higher proportion of parents with knowledge in the post-test.

Table 2: Distribution of parents of adolescents according to the level of knowledge regarding human papilloma virus vaccination amongst the three groups in pre-test and post-test (n=120)

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Paired t-test was done to identify the statistical significance of the different methods of education. [Table 3] depicts the paired t-test analysis done to identify the statistical significance of the difference in pre- and post-test knowledge regarding HPV vaccination over the education programmes. The P values of all the three groups were <0.05 which showed that there was a significant improvement of knowledge amongst the parents of adolescents after administration of the education programme using any method.

Table 3: Paired t-test analysis for statistical significance of pre- and post-test knowledge regarding human papilloma virus vaccination over school education programmes (n=360)

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Data analysis revealed that in the pre-test, the mean knowledge score of parents in Group 1 was 4.95 (standard deviation [SD] = 4.71), in Group 2 was 6.33 (SD = 4.76) and in Group 3 was 5.73 (SD = 4.91). All groups had poor knowledge on HPV and vaccination. In the post-test, the knowledge scores increased to 39 (32.5), 13 (10.8) and 55 (45.8) in all the three groups, respectively.

Comparison of pre- and post-test knowledge of the parents of adolescents regarding HPV vaccination between the three groups was done using one-way ANOVA [Table 4]. Comparison of the pre-test scores between the three groups revealed F_ratio of 2.507 with P = 0.083 which was more than 0.05 and hence not significant. There was no difference between the pre-test knowledge scores amongst the three groups, and they were homogenous. In the post-test, the F_ratio was 51.927 with P = 0.000, showing that there was a significant difference between the different methods of school-based education. The mean percentage enhancement of knowledge was 37.2% in Group 1, 44.6% in Group 2 and 25.20% in Group 3. The intervention used in Group 2, short film, had a better effect on the improvement of knowledge followed by lecture and self-learning booklet [Figure 2].

Table 4: Comparison of pre- and post-test knowledge of parents of adolescents regarding human papilloma virus vaccination between the three groups of the study

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Figure 2: Mean percentage of enhancement of knowledge

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Discussion

Through this study, the researchers were able to identify the knowledge of the parents of adolescents on HPV vaccination and the effect of the education programme using different teaching methodologies. The study was guided by the application of King's goal attainment theory. The analysis revealed that the pre-test knowledge of parents of adolescents regarding HPV infection and its vaccination was poor. This was consistent with the study conducted by Sitaresmi et al.^[27] on the improvement of parents' awareness, knowledge, perception and acceptability of HPV vaccination after a structured educational intervention where they found that in the pre-test, only 49.2% of parents had heard about HPV infection and only 48.8% had heard about HPV vaccine.

In November 2020, the WHO published the global strategy to accelerate the elimination of cervical cancer as a public health problem. The vision is to create a world where cervical cancer is eliminated as a public health problem. A 90-70-90 target was set for the countries to be achieved by 2030. The target aims that by 2030 90% of girls would be fully vaccinated with HPV vaccine by the age of 15 years, 70% of women would be screened with a high performance test at 35 years of age and again at 45 years and 90% of women identified with cervical disease would be receiving treatment. Awareness needs to be created amongst the parents so that they vaccinate their children. Education programme conducted through the school is a good intervention to create awareness amongst the parents. The researchers found that all the three methods of the education programme, namely lecture, short film screening and self-learning booklet, had a significant impact on the knowledge of parents. All the three methods helped improve their knowledge. The study finding was in alignment with the findings of Suarez Mora et al., 2018,^[28] who conducted a study with the aim to evaluate HPV and cervical cancer knowledge in a high-risk population and determine their knowledge and attitudes towards HPV vaccination after screening an educational video. The knowledge scores improved after the educational intervention (mean scores: 9.6–14.4).

Although all the three methods of education were effective, there was a significant difference between the post-test scores of the parents amongst the three groups. The mean percentage improvement of knowledge scores was the highest in Group 2 administered with short film (44.6%) followed by Group 1 who listened to the lecture (37.2%) and Group 3 where a self-learning booklet was shared (25.2%). Short film caters to the various senses of the individual and also reaches the emotion of the parents. Hence, it might have yielded better results compared with the other two methods. As short film is the best method, it can be screened during the parents' meeting at the school, incorporating it into the school health education programme. The short film can be disseminated widely through the schools for better reach in the community. Lecture method is also found to be good, but the challenge is that the health educator has to be present on the spot, during the parents' meeting to deliver the lecture. It is feasible for schools where a school health nurse is placed. The advantage of using the self-learning booklet is that it can be distributed to the parents through the students also. This helps to reach parents who do not turn up for the meetings. In schools where the parents are not gathered for meetings but meet the teacher individually, the self-learning booklet can be distributed to the parents individually. Hence, based on the school environment and the feasibility, the appropriate method that suits the school can be used.

Limitations

There was no way to know whether the booklet was read by participants. This could have been the reason for low scores in the post-test. There was no control over the test performance online.

Conclusion

School-based education programmes are helpful in increasing the knowledge and awareness of parents of adolescents on HPV vaccination. Any method of the education programme can be used to create awareness. However, screening of short film with complete information about HPV infection, its mode of transmission, diseases it causes, vaccination for prevention and details of vaccination has more effect on the knowledge of parents than lecture method and sharing of self-learning booklet. Such innovative teaching methods can be used to reach the parents and thereby ensure the vaccination of adolescents towards prevention of cancers caused by HPV infection. King's goal attainment theory provided the broad framework for the systematic conduction of the study. Application of nursing theories to guide research process is valuable as it enables researchers to stay on track and achieve the intended outcome of the research.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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