Of the 546 parents who were invited, 513 parents attended the structured-educational intervention (response rate was 94%), seven parents were excluded due to inability to read and write, resulting in a total data set of 506 participants. The majority of the respondents are mothers (92.8%), with a median age of 40 years, and the majority are Moslem (98.2%). Forty-three participants (8.8%) experienced a history of any type of cancer in their family, and 4.4% mentioned that their daughter had already received the HPV vaccination (Table 1).
Table 1. Characteristics of respondents
|
N
|
%
|
Characteristics
|
|
|
Gender (n=497)
|
|
|
Male
|
36
|
7,2
|
Female
|
461
|
92,8
|
Age (n=488)
|
|
|
<45 years old
|
342
|
70,1
|
>45 years old
|
146
|
29,9
|
Religion (n=498)
|
|
|
Islam
|
489
|
98,2
|
Non-Islam
|
9
|
1,8
|
Education (n=494)
|
|
|
Basic education
|
222
|
44,9
|
Higher education
|
272
|
55,1
|
Employment Status (n=506)
|
|
|
Employed
|
343
|
67,8
|
Unemployed
|
163
|
32,2
|
Health insurance (n=506)
|
|
|
Yes
|
385
|
76,1
|
No
|
121
|
23,9
|
Number of children in family (n=488)
|
|
|
<=2
|
79
|
16,2
|
>2
|
409
|
83,8
|
monthly Expense (n=483)
|
|
|
>1500000 (>125 US $)
|
264
|
54,7
|
<=1500000 (< 125 US $)
|
219
|
45,3
|
History of any cancer in the family (n=488)
|
|
|
Yes
|
43
|
8,8
|
No
|
445
|
91,2
|
Awareness, knowledge, and perceptions of HPV infection, cervical cancer, and HPV vaccination before the structured-educational intervention
The majority of the parents had heard about sexually transmitted infections (STIs) (72.7%) and cervical cancer (73.7). However, only 46.2% of them had ever heard about HPV infection, and 46.2 % of them mentioned that HPV caused cervical cancer. The majority (76.5%) of respondents already knew that the vaccination could prevent infection, but only 44.1% of parents had ever heard of the HPV vaccination (Table 2).
Table 2. Parent’s knowledge before and after a structured-educational intervention
Awareness and knowledge
|
Correct response
|
|
Before
|
After
|
p
|
|
n (%)
|
n (%)
|
|
Awareness
|
|
|
|
Have you ever heard of Sexually Transmitted Infections (STIs)? (Yes)
|
368 (72.7)
|
404 (79.8)
|
<0.001
|
Have you ever heard of HPV infection? (Yes)
|
234 (46.2)
|
349 (69.0)
|
<0.001
|
Have you ever heard of Cervical Cancer? (Yes)
|
373 (73.7)
|
411 (81.2)
|
<0.001
|
Have you ever heard of HPV Vaccination? (Yes)
|
223 (44.1)
|
354 (70.0)
|
<0.001
|
|
|
|
|
Knowledge of STIs
|
|
|
|
Which one is Sexually Transmitted Infections (STIs)?
|
|
|
|
HPV (Yes)
|
142 (35.2)
|
317 (78.7)
|
<0.001
|
HIV (Yes)
|
261 (64.4)
|
338 (83.5)
|
<0.001
|
Syphilis (Yes)
|
152 (40.0)
|
284 (74.7)
|
<0.001
|
Gonorrhea (Yes)
|
84 (22.6)
|
237 (63.9)
|
<0.001
|
Herpes simplex virus (Yes)
|
104 (27.9)
|
261 (70.0)
|
<0.001
|
Which one is the cause of STIs?
|
|
|
|
Having sex with STIs patient (Yes)
|
287 (66.6)
|
368 (85.4)
|
<0.001
|
Kissing with STIs patient (Yes)
|
83 (20.9)
|
45 (11.3)
|
<0.001
|
Swimming in the pool with STIs patient (No)
|
97 (25.8)
|
255 (67.8)
|
<0.001
|
Hugging with STIs patient (No)
|
131 (34.6)
|
259 (68.3 )
|
<0.001
|
Which one this condition caused by HPV
|
|
|
|
Cervical cancer (Yes)
|
192 (45.0)
|
345 (80.8)
|
<0.001
|
Genital warts (Yes)
|
96 (24.6)
|
285 (72.9)
|
<0.001
|
Oral cancer (Yes)
|
83 (21.2)
|
286 (73.1)
|
<0.001
|
Urinary Tract Infection (UTIs) (No)
|
64 (17.1)
|
160 (42.8)
|
<0.001
|
Bladder cancer (No)
|
46 (12.3)
|
104 (27.7)
|
<0.001
|
|
|
|
|
Knowledge about Cervical Cancer
|
|
|
|
Keep clean environment can reduce risk of Ca Cervic (No)
|
76 (17.8)
|
177 (41.5)
|
<0.001
|
Cervical cancer can occur in woman and man (No)
|
183 (42.7)
|
216 (50.3)
|
<0.001
|
Cervical cancer is caused by HPV infection (Yes)
|
235 (55.3)
|
359 (84.5)
|
<0.001
|
|
|
|
|
Knowledge about HPV Vaccination
|
|
|
|
Vaccination is one way to prevent infections (Yes)
|
325 (76.5)
|
379 (89.2)
|
<0.001
|
HPV vaccine does not give protection from Ca cancer (No)
|
174 (42.1)
|
285 (69.0
|
<0.001
|
HPV vaccine can be given to woman and man (Yes)
|
87 (22.0)
|
261 (65.9)
|
<0.001
|
HPV vaccine is given to children (No)
|
58 (17.1)
|
142 (41.8)
|
<0.001
|
HPV vaccine is given to Adolescent (Yes)
|
224 (58.5)
|
326 (85.1)
|
<0.001
|
At baseline, the majority of parents already have a strong perception of the severity of cervical cancer. Most parents were "agree/strongly agree" that cervical cancer is a dangerous cancer (87.8%), and every woman was at risk of having cervical cancer (72.6%). However, the perception of the risk of having HPV infection was low, with only 40.3% strongly agree or agree that they are at risk of having HPV infection. The perceptions of the benefit and safety of the HPV vaccine were high; 78.6% of respondents strongly agree/agree that they believe HPV vaccination is useful for preventing cervical cancer, and 69.7% of them strongly agree/agree that they believe HPV vaccine is safe. (Table 3).
Table 3. Parent’s perception before and after a structured-educational intervention
Perception
|
agree/strongly agree
|
|
Before
n (%)
|
After
n (%)
|
p
|
Perception toward HPV infection
|
|
|
|
HPV infection is a common STIs in woman
|
266 (57.7)
|
368 (80.5)
|
<0.001
|
All person, both woman and man are at risk for having HPV infection
|
186 (40.3)
|
365 (81.8)
|
<0.001
|
HPV infection can cause cervical cancer
|
280 (61.5)
|
381 (84.3)
|
<0.001
|
HPV infection is a major cause of women death
|
276 (61.5)
|
362 (81)
|
<0.001
|
Behavioural can prevent HPV infection
|
|
|
|
No sex before marriage
|
420 (88.2)
|
430 (94.7)
|
<0.001
|
HPV vaccination
|
385 (84.8)
|
411 (92.6)
|
<0.001
|
Perception toward cervical cancer
|
|
|
|
Cervical cancer is a dangerous cancer
|
416 (87.8)
|
437 (95.8)
|
<0.001
|
Every woman is at risk of developing cervical cancer
|
337 (72.6)
|
394 (86.6)
|
<0.001
|
Perception toward HPV vaccination
|
|
|
|
I believe HPV vaccination is useful for preventing cervical cancer
|
367 (78.6)
|
415 (92.7)
|
<0.001
|
I believe HPV vaccine is safe
|
317 (69.7)
|
402 (91.0)
|
<0.001
|
Factors associated with HPV vaccine's acceptability after the structured-educational intervention
In the bivariate analysis, we found that knowledge and perceptions of HPV infection, cervical cancer, and HPV vaccine were predictive of vaccine acceptability. There was no correlation between the sociodemographic characteristics of the respondents with HPV vaccination acceptability. In the multivariate analysis, we found that better knowledge of HPV vaccination and more positive perceptions of HPV vaccine were predictive of vaccine acceptability with OR 1.90 (95%CI:1.40-2.57) and OR 1.31(95%CI:1.05-1.63), respectively (Table 5).
Table 4. Total score of parent’s awareness, knowledge and perception before and after structured-educational intervention
|
|
Mean (SD)
|
Median
|
p
|
Awareness
|
Before
|
2.36 (1.21)
|
2
|
<0.001
|
|
After
|
3.00 (1.24)
|
4
|
|
Knowledge of HPV infection
|
Before
|
4.11 (3.80)
|
3
|
<0.001
|
|
After
|
7.65 (4.64)
|
10
|
|
Perception of HPV infection
|
Before
|
22.80 (7.03)
|
24
|
<0.001
|
|
After
|
24.79 (8.88)
|
27
|
|
Knowledge of cervical cancer
|
Before
|
1.14 (0.95)
|
1
|
<0.001
|
|
After
|
1.51 (0.99)
|
2
|
|
Perception of cervical cancer
|
Before
|
7.67 (2.47)
|
8
|
<0.001
|
|
After
|
8.03 (2.93)
|
9
|
|
Knowledge of HPV vaccination
|
Before
|
1.95 (1.48)
|
2
|
<0.001
|
|
After
|
3.05 (1.72)
|
3
|
|
Perception of HPV vaccination
|
Before
|
7.31 (2.57)
|
8
|
<0.001
|
|
After
|
7.81 (3.07)
|
9
|
|
Higher scores reflex higher awareness, knowledge, and perception. Score of awareness ranged from 0-4, knowledge of HPV infection ranged from 0-14, knowledge of cervical cancer ranged from 0-3, knowledge of HPV infection ranged from 0-5, perception of HPV infection ranged from 6-30, perception of cervical cancer ranged from 2-10, and perception of HPV infection ranged 2-10.
Table 5. Bivariate and multivariate analysis of awareness, knowledge, perception and acceptability of HPV vaccine: after intervention program
Analysis
|
Bivariate analysis
|
Multivariate analysis
|
|
OR (95% CI)
|
p
|
OR (95% CI)
|
p
|
Awareness
|
1.56 (1.22-2.00)
|
0.000
|
0.86 (0.60-1.25)
|
0.448
|
Knowledge of STIs
|
1.21 (1.13-1.29)
|
0.000
|
1.05 (0.92-1.12)
|
0.479
|
Knowledge about Cervical Cancer
|
2.09 (1.48-2.96)
|
0.000
|
0.78 (0.94-0.59)
|
0,787
|
Knowledge about HPV Vaccination
|
2.70 (1.70-2.53)
|
0.000
|
1.90 (1.40-2.57)
|
0.000
|
Perception about HPV infection
|
1.13 (1.07-1.18)
|
0.000
|
0.97 (0.89-1.06)
|
0.599
|
Perception about cervical cancer
|
1.30 (1.11-1.52)
|
0.000
|
0.93 (0.75-1.15)
|
0.525
|
Perception about HPV vaccination
|
1.62 (1.35-1.92)
|
0.000
|
1.31 (1.05-1.63)
|
0.016
|
Considerations for accepting HPV vaccinations were free of charge (according to 95.5% of respondents), the vaccine was included in NIP (according to 97.1% of respondents), the vaccine is considered safe by Moslem standards or halal (98.0%), scientifically safe (97.0) and effective in preventing the disease (97.7%). The three most important considerations were free of charge, the vaccine is halal, and the vaccine is effective.
Impact of the structured-educational intervention
After the structured-educational intervention, there were significant improvements in parents’ awareness, knowledge, and perceptions of HPV infection, cervical cancer, and the vaccine, all p<0.001(Tables 2, 3 and 4). Parental acceptability of the HPV vaccination for their children increased significantly (from 74.3% to 87.4%; p<0.001). There was a significant correlation between increasing vaccine acceptability with improvement of awareness (r=0.33, p<0.001), knowledge of HPV infection (r=0.35, p<0.001), cervical cancer (r=0.35, p<0.001) and HPV vaccination (r= 0.47, p<0.001) and perceptions of the HPV infection (r=0.36, p<0.001), cervical cancer (r=0.35, p<0.001) and HPV vaccination (r=0.53, p<0.001).