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ORIGINAL ARTICLE
Year : 2022  |  Volume : 66  |  Issue : 2  |  Page : 104-108  

Online educational program for parents of adolescents on human papillomavirus vaccination during COVID pandemic: A feasibility check


1 Scholar, College of Nursing, Pondicherry Institute of Medical Sciences, Puducherry, India
2 Professor and Head, Department of Community Health Nursing, College of Nursing, Pondicherry Institute of Medical Sciences, Puducherry, India
3 Professor Cum Assistant Registrar, College of Nursing, Pondicherry Institute of Medical Sciences, Puducherry, India
4 Professor Cum Principal, College of Nursing, Pondicherry Institute of Medical Sciences, Puducherry, India

Date of Submission14-Sep-2021
Date of Decision12-Oct-2021
Date of Acceptance15-Nov-2021
Date of Web Publication12-Jul-2022

Correspondence Address:
C T Abra Pearl
B1, CF Hospital Quarters, Oddanchatram, Dindigul, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.ijph_1791_21

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   Abstract 


Background: Human papillomavirus (HPV) vaccination for adolescents helps in the prevention of preventable cancers caused due to HPV infection. However, many adolescents are not vaccinated due to lack of knowledge among parents. Objective: This study aimed to compare the level of knowledge and attitude of parents on HPV vaccination before and after the online educational intervention. Methods: A cross-sectional pilot study was conducted among a sample of 45 parents of adolescents studying in class 7th–9th. The parents were selected two-stage simple random sampling and assigned randomly to three groups with three different methods of education – online lecture with PowerPoint presentation, online short film with discussion, and self-learning online booklet. Pre- and postintervention knowledge was assessed with a structured questionnaire and attitude with modified Likert scale administered online. Wilcoxon and Kruskal–Wallis tests were used to find the statistical significance in the study. Results: Only 36% of samples stated that they have not heard about HPV vaccination, while others had heard from health-care workers, family members, friends, or television, but their knowledge was inadequate. In all the three groups, there was significant improvement in level of knowledge, but there was no significant difference in attitude. The posttest knowledge scores of parents educated with short film were significantly more than the other two interventions. Conclusion: Online educational programs were found to be effective in improving the knowledge of parents on HPV vaccination and of the three methods; short film was more effective than the other two methods.

Keywords: Adolescents, human papillomavirus, leaflet, lecture, online education, short film


How to cite this article:
Abra Pearl C T, Navaneetha M, Malarvilizhi S, Mony K. Online educational program for parents of adolescents on human papillomavirus vaccination during COVID pandemic: A feasibility check. Indian J Public Health 2022;66:104-8

How to cite this URL:
Abra Pearl C T, Navaneetha M, Malarvilizhi S, Mony K. Online educational program for parents of adolescents on human papillomavirus vaccination during COVID pandemic: A feasibility check. Indian J Public Health [serial online] 2022 [cited 2022 Aug 16];66:104-8. Available from: https://www.ijph.in/text.asp?2022/66/2/104/350660




   Introduction Top


Cervical cancer is the second most common cause of cancer death in women, with an estimated 510,000 newly diagnosed cervical cancer cases and 288,000 deaths.[1] Cervical cancer accounted for an estimated 96,922 new cases and 60,078 deaths in India in 2018, which is close to one-fifth of the global burden of this cancer.[2] Virtually, all cervical cancers are causally related to infections by human papillomavirus (HPV).[3] HPV Types 16 and 18 account for 80%–85% of cervical cancers in the country.[4] Approximately 80%–90% of anal cancers are caused by either HPV16 or HPV18.[5] At least 40% of vulvar cancers are HPV related.[6] It is found that some types of penile,[7] vaginal,[8] urethral, and head-and-neck cancers[9] contain carcinogenic HPV types. Almost 90% of anogenital warts are caused by HPV Types 6 or 11.[10] HPV 6 and 11 have been reported to cause papillomas of the larynx, esophagus, and bronchi which may transform into carcinomas later.[11] At any given time, about 6.6% of women in the general population harbor cervical HPV infection.[12]

However, there are vaccines that can prevent infection with HPV which is the most common cause of genital and oropharyngeal cancers. At present, two types of HPV vaccines are available. Gardasil, a quadrivalent vaccine, protects against HPV Types 6, 11, 16, and 18 and Cervarix, a bivalent vaccine, protects against Types 16 and 18. The aim of vaccination is to reduce the incidence of genital cancers, warts and reduction in the papillomatosis of the oropharynx, esophagus, and larynx.[13]

The Center for Disease Control recommends HPV vaccine for girls and boys aged 9–13 years and two doses protect them against HPV infections that cause genital warts and cervical cancer.[14] Three doses remain recommended for persons who initiate the vaccination series at ages 15 through 26 years and for immune-compromised persons.[14]

Two vaccines such as Gardasil and Cervarix are available in India. Although the WHO recommendation dates back to 2006, it is still found that most of the adolescents are not vaccinated at the right time.[15] This may be due to lack of awareness among the public. The American Cancer Society guideline for HPV vaccine use to prevent cervical cancer and its precursors states that there is a critical need for education of providers, policy-makers, parents, adolescents, and young women about cervical cancer prevention and vaccination.[16]

The report of a qualitative study assessing the views of policy-makers and other stakeholders on perspectives on HPV vaccine introduction in Tamil Nadu, India, states that because of high enrollment and low dropout rates in Tamil Nadu, most 10–14-year-old girls could be reached through schools and by educating them on HPV vaccination.[17] Hence, the school can be a portal to reach the parents of adolescents. The implementation of an effective program to increase the acceptance rate of HPV vaccination requires educational strategies aimed at involving parents, supported by health professionals.[18] Hence, it was decided to undertake a study to identify the best educational methodology to reach the parents of adolescents to improve their knowledge and attitude toward HPV vaccination and thereby encourage the uptake of vaccines.

As the COVID pandemic has struck the country, the schools have resolved to educating children through online mode. The possibility of educating the parents through the online methodology, comparing the effectiveness of lecture with PowerPoint presentation, short film with discussion, and sharing a self-learning booklet were explored through this study.


   Materials and Methods Top


Study design and study population

This study adopted the quantitative research approach with experimental pre- and posttest design. The study was conducted in the month of March–May 2020. The study population were parents of adolescents (either mother or father) studying in the 7th, 8th, and 9th standard of school education. The parents who could understand English or Tamil and comfortable in handling a smart phone were included in the study.

Study setting and sample selection

The study was conducted at Oddanchatram, a taluk under Dindigul District in Tamil Nadu. The parents were reached through three matriculation schools. The pilot study was conducted among a sample of 45 parents and an equal size of 15 in each group. The study adopted a two-stage sampling technique for randomization and recruitment of the participants. The primary sampling units were the 17 schools in Oddanchatram taluk. By lottery method, each school was selected assigned to a specific interventional group. School 1: Group 1 – lecture with PowerPoint presentation method; School 2: Group 2 – short film with discussion method; and School 3: Group 3 – online self-learning booklet method. The details of the parents were obtained from the teachers and the parents were contacted over the phone to gain informed consent. Among the parents who fulfilled the inclusion criteria and were willing to participate in the study, a total of 45 parents (secondary sampling units), 15 in each group, were selected by lottery method. As this is a feasibility study, 10% of the samples from the actual samples calculated using power analysis to be included in the larger study were selected. If the selected participant did not turn up for the online teaching session, replacement of the sample was done following the same sampling method.

Ethical considerations

The study was approved by the Institutional Review Board, of Pondicherry Institute of Medical Sciences (Approval number: IRB –PIMS/Ph.D.(N)/2018/25). Informed consent was obtained from each subject before the commencement of the study. Privacy and confidentiality were maintained throughout the study.

Tools and techniques for data collection

The pre- and posttest data were collected with the use of a validated structured tool. The study tool had three sections. Section A consisted of the information regarding the sociodemographic details of the participants such as gender, parent who is participating in the study, family type, religion, area of residence, education status of father and mother, occupation of father and mother, monthly income of the family, exposure to information about HPV vaccination, history of cancer in the family, and vaccination status of the child. Information on the knowledge of parents on HPV infection and vaccination was collected in Section B using a structured questionnaire and the attitude of the parents on HPV vaccination was observed using a 5-point modified Likert scale in Section C. The study tool was shared online through Google Forms with the subjects.

The intervention package consisted of the information on HPV infection, its causes and mode of transmission, signs and symptoms, the diseases that are caused because of infection, the vaccine available for prevention of HPV infection, and the advantages and details of vaccination and its side effects. After the pretest, 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 through the Zoom platform. For Group 2, through the Zoom platform, a prerecorded short film was played which was followed by discussion. For Group 3, after the pretest, a self-learning booklet was shared online. After an interval of 1 week of administering the interventional package, posttest was done by sending the study tool through Google Forms to the subjects.

Statistical analysis

The data were collected, coded, checked, and entered into MS Excel and were analyzed using statistical software SPSS (version 21.0) IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp. The sociodemographic variables, the level of knowledge, and attitude were expressed in terms of proportion and percentage. The comparison of the pre and post test scores for knowledge and attitude within the individual groups were done using nonparametric test for paired outcomes, the Wilcoxon test. The comparison of post test scores between the three groups was done using nonparametric analysis of variance, Kruskal– Wallis test. Based on the nonnormality of data, the level of significance (α = 5%) P = 0.05 was considered to be statistically significant.


   Results Top


Sociodemographic variables

Among the selected participants, 82% of the parents were the mother of the adolescent, 58% lived in nuclear families, 64% were Hindus by religion, and 47% lived in the rural area. Most of the parents were either graduates or postgraduates. More than 60% of the fathers were non health-care professionals, whereas 42% of the mothers were unemployed. Of all the samples, 36% said that they have not heard about HPV vaccination and most of them, 73%, reported that they have not vaccinated their child with HPV vaccination. The three groups of parents subjected to different methods of teaching were found to be homogenous.

Knowledge about human papillomavirus infection and vaccination

In the pretest – Group 1, most of the subjects (66.7%) had inadequate knowledge (<50%) and in the posttest, 20% had gained adequate knowledge (>75%). In Group 2 pretest, 66.7% had inadequate knowledge, while in posttest, 73.3% had gained adequate knowledge. In Group 3, most of the subjects, 66.7%, had inadequate knowledge in the pretest and 13.3% had gained adequate knowledge in the posttest. The pretest mean percentage score of Group 1 was 32.3%, Group 2 was 33.6%, and Group 3 was 32.0%, whereas the posttest mean knowledge scores were improved to 65.1% in Group 1, 79.4% in Group 2, and 63.8% in Group 3.

Attitude about human papillomavirus vaccination

In pretest, 26.7% of the subjects had unfavorable attitude (<50%) in Group 1, 40.0% had unfavorable attitude in Group 2, and 46.7% had unfavorable attitude in Group 3, the remaining proportion had moderately favorable attitude (<50.0%) and it was found that none of the subjects had favorable attitude (>75%) toward HPV vaccination. But in posttest, it was found that 20.0% had favorable attitude (>75%) in Group 1, 60.0% had favorable attitude in Group 2, and 26.7% had favorable attitude, the remaining proportion in each group had moderately favorable attitude and none of them had unfavorable attitude toward HPV vaccination. The pretest mean percentage score for Group 1 was 51.9%, Group 2, was 52.7% and Group 3 was 50.6%. The posttest mean percentage attitude of Group 1 was 68.2%, Group 2 was 75.6%, and Group 3 was 69.7%.

Effectiveness of the online school-based education program

The pre- and posttest comparison (Wilcoxon test) of knowledge in each group was found to be invariably significant (P < 0.05). It implied that each mode of teaching was individually effective in improving the knowledge on HPV vaccination. Between group comparison (Kruskal–Wallis test) of pre- and posttest scores over the groups resulted that not significant for pretest scores (P > 0.05) and significant for posttest scores (P < 0.05). It implied that the knowledge on HPV vaccination in pretest was similar over the groups but, in posttest it differs significantly. Further, it evidence that the increase in knowledge among who were educated with the online screening of the short film were comparably more other two groups. [Table 1] depicts the statistical analysis done to find the effectiveness of the online education program on the knowledge of the parents of adolescents on HPV vaccination. [Table 2] presents the statistical analysis done to elicit the effectiveness of the online school based education program on the attitude of the parents of adolescents on HPV vaccination.
Table 1: Mean, standard deviation, mean percent of pre- and posttest knowledge regarding human papillomavirus vaccination; the pre- and posttest comparison (Wilcoxon test) of knowledge within the groups and between group comparison (Kruskal–Wallis test) of pre- and posttest scores of knowledge over the school-based education programs (n=15)

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Table 2: Mean, standard deviation and mean percent of pre- and posttest attitude regarding human papillomavirus vaccination ; pre- and posttest comparison (Wilcoxon test) of attitude; Between group comparison (Kruskal–Wallis test) of pre- and posttest scores of attitude over the school-based education programs (n=15)

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The pre- and posttest comparison (Wilcoxon test) of attitude in each group was found to be invariably significant (P < 0.05). It implied that each mode of teaching was individually effective in improving the attitude on HPV vaccination. The comparison of the pre test attitude scores between the groups (Kruskal–Wallis test) showed no significant difference (p>0.05). But the comparison of the post test attitude scores between the groups showed significant difference (P < 0.05). It implied that the attitude on HPV vaccination in pretest was similar over the groups but, in posttest, it differs significantly. Further, it evidence that the increase in attitude among who were educated with the online screening of the short film was comparably more other two groups.


   Discussion Top


The objective of this small scale study was to identify the feasibility of conducting online educational programs for the parents of adolescents on HPV vaccination. From the study, it is found that most of the subjects in the study groups had heard about HPV vaccination (64.44%) and most of the parents of the adolescents were literate. But still, the level of knowledge of the subjects was found to be inadequate in the pretest. This may be due to the lack of in-depth knowledge of parents on HPV vaccination. This was in line with the previous literature reviewed by the researchers.

Influence of online education on knowledge

The online educational program focused on improving the knowledge of the parents on HPV vaccination. It was found that there was a significant increase in the knowledge of the parents in all the three groups leading to the acceptance of the research hypothesis which stated that there will be a significant difference between the pre- and posttest knowledge of the parents of the adolescents on HPV vaccination. Similar results have been obtained by other researchers in the similar field of study.[19],[20],[21] Of the three methods of education, it was found that the group who had received the education in the form of watching an online short film followed by discussion had a significantly higher mean improvement of knowledge compared with the other two groups who received education through online lecture and online self-learning booklet. Hence, the research hypothesis which stated that there will be a significant difference between the mean improvement of knowledge in the posttest scores of the parents of adolescents between the groups was accepted. Appropriate health education programs are essential to create awareness among mothers.[22],[23]

Influence of online education on attitude

An objective of the study was to identify the effective of the online education program on the attitude of parents of adolescents on HPV vaccination. It was found that the pretest mean attitude percentage in the three groups was 72%, 67.1%, and 71%, respectively. The posttest mean attitude percentage in the three groups was 74.1%, 72%, and 76.8%, respectively. The Wilcoxon test value between the pre- and the posttest scores was statistically not significant. Hence, the research hypothesis stating that there will be significant difference between the pre- and posttest attitude of the parents of adolescents on HPV vaccination in the three interventional groups was rejected. As per the literature review, this was found to be in line with the study by Kwan et al.[19] where they noted that the attitude of the subjects was good[24] even before the educational package. This may be a general attitude toward vaccination as a measure of preventing diseases.[25]

Feasibility of online educational program

Online education has become the new normal in today's educational scenario. The pandemic has changed the mode of education where students learn from the comfort of their home. This study aimed at assessing the feasibility of reaching the parents of adolescents through online educational program to improve their knowledge and attitude on HPV vaccination. The access to the parents was gained through the schoolteachers who had the contact details of the parents. The parents were contacted through the phone to gain informed consent and understand their ability to manage smart phones. Parents who were willing and were good in handling smart phones were selected and by lottery method, the subjects for the study were recruited. Five more samples in each group were recruited to address issues of dropouts.

The informed consent was obtained through Google Forms. The pre- and posttest structured questionnaires also were sent to the parents and received as Google Forms. Online educational sessions in Group 1 and 2 were conducted through the Zoom platform. The subjects who had participated in the pretest were invited to the online educational program in the respective method of education – lecture with PowerPoint presentation or short film screening with discussion. For Group 3, the online self-learning booklet was sent to their WhatsApp number as a PDF document.

Through the systematic conduct of the online educational program, the researcher found that there is the possibility of reaching the parents and educating them on HPV vaccination. By participating in the online program, the parents expressed that they were able to participate in the program from their homes, which reduced the time of travel and setting apart a specific time to reach the school for the educational program. As the group was small, the researcher was able to provide individual attention to each parent. In Group 2, the discussion time was effectively utilized to clarify their doubts. Most of the parents were familiar in using Google Forms as they had used it to help their children complete their school assignments.

There are certain limitations. As the intervention was online education, samples who were competent in using smart phones were only included in the study, the parents who are not mobile savvy or technically illiterate were not reached through this study.


   Conclusion Top


The knowledge of the parents of adolescents on HPV vaccination is limited even though they have a positive attitude toward vaccination. Online school-based education program is effective in reaching the parents and improving their knowledge and impacting their attitude on HPV vaccination. Screening a short film followed by open discussion is the better online educational method to educate parents. Educative short films can be prepared and shared with the parents through the online platform. Approaching the parents through the school can improve awareness and thereby facilitate the vaccine uptake for their adolescent children.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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