Effect of health education on acceptance of human papilloma virus vaccine among parents of adolescent girls of Bishnupur, Manipur: A quasi-experimental study

Material & Methods

A quasi-experimental study was conducted from February to May 2023 among parents of adolescent girls aged 9-14 yr in the field practice area of the Rural Health Training Centre, Bishnupur. Manipur has 2,95,130 adolescent females as per United Nations Population Fund (UNFPA) Report 2011¹⁷. The district of Bishnupur has 67 per cent coverage of all essential vaccinations among children aged 12-23 months (NFHS-5)¹⁸. The participants residing in the district for at least one year and those using WhatsApp mobile application were included, and those households in which, even after two visits, no one could be contacted were excluded. Ethical approval was obtained from the Institutional Research Ethics Board. The trial was prospectively registered (CTRI/2023/02/049771) in the Clinical Trial Registry of India.

Intervention

The intervention comprised three sessions followed by post-tests 1 and 2 with a 2-wk interval between each, as shown in figure. During the first session, researchers collected baseline data. They administered a pretest, followed by the first educational session- a pamphlet-aided face-to-face discussion on the signs and symptoms of cervical cancer and the HPV vaccine. The pamphlet (Supplementary Fig. 1) was in the local language and English. Two wk later, for the second session, a two-minute awareness video on HPV vaccine advantages and hurdles was distributed over WhatsApp ( https://drive.google.com/file/d/1jiGVXEfFzg4SNiV6bpcbK5N7aR7NgD7C/view?usp=drive_link ). After two wk, for the third session, IEC images (Supplementary Fig. 2) on HPV vaccination rollout in UIP, vaccination availability, and pricing in Manipur were sent via WhatsApp mobile application. Researchers contacted the participants by phone after sending the interventions to confirm if they saw and understood the materials. A quiz followed by post-test 1 was done face-to-face at participants’ houses two wk later. Post-test 2 was conducted two wk after post-test 1.

Supplementary Fig 1

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Supplementary Fig 2

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Figure.

Flowchart of health educational intervention. HPV, human papillomavirus; UIP, universal immunization programme; IEC, information education communication; wk, week.

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Results

There was no loss to follow up during the study, and 70 respondents completed both the pretest and post-tests. All background characteristics are shown in Table I. The median age of the participants was 38 yr (IQR: 34-44), with the majority 54 (77.1%) of the respondents being mothers. Most participants, i.e., 41 (58.6%), belonged to the Hindu religion, and 39 (59.7%) were educated up to secondary school level or below. The majority, 40 (57.1%), were unemployed, and 26 (37.2%) economically belonged to the upper-middle or upper-class families as per the modified BG Prasad scale¹⁰. Most participants, 65 (92.9%), had their children with UIP vaccination status as complete. Among the participants 15 (21.5%) had experienced cancer themselves or with their family members or relatives and only six (8.6%) had awareness about HPV vaccine.

The baseline acceptance for HPV vaccine among parents of adolescent girls was 61.5 per cent. During pretest, when asked about vaccinating their daughter with HPV vaccine, 43 (61.5%) responded ‘definitely yes’, 26 (37.1%) said ‘probably yes’ and 1 (1.4%) said ‘probably not’.

Table II shows that HPV vaccine acceptance improved significantly from 61.5 to 81.4 to 88.6 per cent (P=0.001). There was a significant increase in mean scores of ‘perceived susceptibility’ (P<0.001) and ‘perceived benefits’ (P<0.001) across different time points, but no statistically significant change in scores of ‘perceived severity’ (P=0.051) and ‘perceived barriers’ (0.367).

Pairwise comparisons (Table III) showed significant improvement in HPV vaccine acceptance at post-test 1 (P=0.022) and 2 (P=0.001) compared to pre-test, respectively but no significant change between post-tests 1 and 2. There was a significant increase in ‘perceived severity’ (P=0.045) at post-test 2 compared to the pre-test. ‘Perceived susceptibility’ and ‘perceived benefits’ increased significantly at post-tests 1 and 2 compared to pretest, but there was no significant change in post-tests 2 and 1 scores. There was no significant association between socio-demographic characteristics and vaccine acceptance in both pre-test and post-test (Supplementary Table I). Distribution of participants responses for each statement based on their attitude and belief of HPV vaccine is mentioned in Supplementary Table II.

Discussion

This community-based quasi-experimental study showed the effectiveness of one-on-one health education on parental HPV vaccine acceptance. Only two participants had children with incomplete UIP vaccination status, the reason for which was the COVID-19 pandemic. The high vaccination coverage (>90%) in the sample compared to that as reported in NFHS 5 (67%) for Bishnupur could be attributed to many factors, such as our participants being selected through a convenience sampling approach, self-reported responses, or in general, increased vaccine acceptance over time.

Studies have shown a lack of awareness of HPV infection and cervical cancer as one of the major reasons for poor HPV vaccine uptake^20,21. In this study, only 8.6 per cent of participants were aware of the vaccine, which could protect against HPV infection and cervical cancer, compared to 22.3 per cent knowledge about the HPV vaccine in a study conducted by Musa et al²² in Nigeria. The difference may be because, in India, campaigns for the HPV vaccine have not yet gained momentum compared to the other routine vaccinations^23,24. Studies have shown that improving knowledge of HPV and cervical cancer increases acceptance of the HPV vaccine^25,26. Those aware of the HPV vaccine had a significant positive association with vaccine acceptance (P=0.010) during the pretest in this study. Educational interventions such as pamphlets and videos have been shown to improve awareness and acceptance. Studies done in Pennsylvania and Chennai demonstrated that video served better than pamphlets or lectures in improving acceptance^12,13.

Previous experiences from Sikkim²⁷ showed that mandatory school enrolment and collaboration between the health and education sectors were critical factors for the high coverage of the HPV vaccine. Even though vaccine rollout in other States of India will be through schools, improving acceptance by approaching parents in the community through one-on-one health education by Accredited Social Health Activists (ASHAs) and healthcare workers will be crucial considering the current era of misinformation and disinformation.

In our study, as captured by pretest, the baseline acceptance of the HPV vaccine among parents of adolescent girls was 61.4 per cent even though awareness was 8.6 per cent. This could have been due to the brief introduction to the HPV vaccine given by researchers after completing the first section of the questionnaire, which could be attributed to factors like trust in healthcare providers and general vaccine acceptance. In post-tests 1 and 2, acceptance increased to 81.4 per cent and 88.6 per cent, respectively, which showed that the health education programme effectively improved parental acceptance of the HPV vaccine. Studies have demonstrated that educational interventions on HPV-related illnesses effectively increase knowledge and vaccine acceptability in America, Malaysia, Korea, Turkey, and Hong Kong^{12,14,15,28,29}.

There was a significant improvement in attitude in perceived benefits and susceptibility domains following the intervention. This is consistent with previous studies^14,30,31, which reported improvement in attitude after providing adequate information through educational intervention. The proportion of people who strongly agreed that HPV infection was harmful increased from 44.3 to 67.2 per cent, and those who strongly agreed that cervical cancer was a serious disease increased from 51.5 to 70 per cent. Similarly, regarding susceptibility, the proportion of those who strongly agreed that their daughter might one day be at risk of HPV infection increased from 5.7 to 35.7 per cent post-intervention. Those who strongly disagreed that they were concerned about the side effects of vaccination increased from 8.6 to 17.1 per cent. Concerns about side effects should be addressed appropriately when vaccine rollout happens. The perception of cost as a barrier increased after intervention, which could have resulted from cost aspects being explained in detail during intervention. Cost concerns should be reduced once the HPV vaccine is rolled out through UIP.

As we used multiple modes such as video, discussion, images and pamphlet along with approaching each participant in person, this must have addressed most of the concerns resulting in the significant increase in acceptance. Educational pamphlet developed for this study may be helpful for providers to guide patients in clinical settings and stakeholders in community settings. Similar to the study conducted by Pearl et al¹³, we didn’t find any significant association between socio-demographic characteristics and vaccine acceptance. This may be due to the selection of participants from a setting with less diverse characteristics.

However, vaccine acceptance attitude may not necessarily convert into vaccinating behaviour. Several factors can influence vaccine acceptance: accessibility, convenience, financial barriers, follow-ups, health literacy, etc. It needs to be assessed later on by follow-up. Similarly, vaccine acceptance cannot be confirmed unless it translates into actual vaccine uptake – a fact that needs long-term follow-up to see how the vaccine coverage peaks once vaccine rollout happens.