'Is It Like One of Those Infectious Kind of Things?' The Importance of Educating Young People about HPV and HPV Vaccination at School

"Study findings demonstrate that it is feasible for educators to teach students about HPV and HPV vaccination, at school, preferably as part of the Health curriculum..., when they are supported by an educator user guide, supplement and user-friendly, age appropriate educational resources."

As part of the National Human Papillomavirus (HPV) Vaccination Program in Australia, which commenced in 2007 for girls and in 2013 for boys, students are primarily vaccinated en masse, on school grounds, after parental/guardian consent is obtained. Research in Australian schools indicates that young people's understanding, self-efficacy, and involvement in decision-making about the HPV vaccine are low, while vaccination-related fear and anxiety are high. Students most often receive little, or no, education at school about HPV or HPV vaccination prior to immunisation. Despite media awareness campaigns, there is also some uncertainty about where young people can and should obtain reliable information about the vaccine. Against this background, the educational intervention evaluated in this paper - "HPV.edu" - aimed to improve student knowledge about HPV vaccination, psycho-social outcomes, and vaccination uptake.

The conceptualisation and design of the study was informed by a broad-based biopsychosocial model, which recognises that young people who are offered the vaccine are individuals acting in a social world that includes their school and community. The research also drew on theories of behaviour change, including the Health Belief Model (HBM), the Theory of Planned Behaviour (TPB), and Social Cognitive Theory.

From 2012 to 2014, the researchers conducted a multi-centre cluster randomised controlled trial (RCT) of an intervention in 40 secondary schools in Western Australia (WA) and South Australia (SA). Students in their first year of high school (year 8), key school personnel (teachers, principals, school nurses), immunisation nurses, and parents/guardians participated. Schools were randomly allocated to intervention (21 schools, 3,806 students) or control (19 schools, 3,159 students). Control schools followed usual practice.

The education resources for study intervention schools were designed to meet the curriculum guide and outcomes for Physical Health and Education in SA and WA. The focus was on developing health literacy, consistent with a strengths-based approach, recognising that schools are key settings for developing health-related knowledge and skills. Specifically, the resources consisted in:

• An educator guide and supplement providing educators with background information regarding the development of the education resources, their relevance to the Australian curriculum, and suggested interactive lesson plans with 9 in-class activities. Five activities focused on HPV and vaccination (e.g., "HPV Bingo"), 2 on the decision-making process (e.g., "Talk with Your Parent"), and 1 on the practical aspects of vaccination day ("Meditation Exercise"), with 1 summary activity.
• An 18-minute DVD/film consisting of 7 chapters, 4 of which focused on HPV and vaccination, 1 of which covered the decision-making process, and 1 of which addressed practical aspects of vaccination day, with a final chapter summarising key information. The DVD was designed to be screened in an interactive way during class time to promote discussion between students and their teacher/school nurse.
• A website (no longer in operation) intending to reinforce the information taught in class. Adolescents could re-watch film clips, sign up to receive reminders about vaccination, and share their stories about being vaccinated.
• A magazine including a range of practical information about HPV and HPV vaccination, and the school vaccination day, in an appealing format. The magazine was designed to be taken home by students to read in their own time.
• An app available on mobile devices across platforms (e.g., an iPad) that contained the DVD chapters, an e-copy of the magazine, and distraction/relaxation methods to be used prior to and during vaccination.

The study included a quantitative evaluation (validated student survey - HPV Adolescent Intervention Questionnaire, or HAVIQ) and a qualitative component (17 focus groups with 111 students, 22 interviews with parents, 11 interviews with school personnel, 10 immunisation team interviews, and 20 school observation logs of vaccination day processes). Also, 71 educator logs were returned (at least 1 per school), which documented the implementation of the educational activities.

The majority of schools reported that teachers taught the education sessions; however, at 5 schools in WA, the school health nurse facilitated these sessions. Of 21 intervention schools, 15 reported the education sessions were conducted prior to students receiving their first school-based vaccinations (pre-HPV dose 1). Across all schools, the average time spent teaching was 56 minutes (range 30 to 112 minutes). Schools used an average of 10 resources, with the DVD and the magazine being most used by educators.

Students in intervention schools had, on average, 65% correct responses to the HAVIQ knowledge questions, which were administered pre-HPV dose 1 of vaccine. This compared to 33% of responses correct by students in control schools. Pre-dose 3 (6 months later) students in intervention schools had on average 53% correct responses to knowledge questions, compared to 32% of responses correct by students in control schools. Greater knowledge and understanding of HPV and HPV vaccination appeared to promote positive attitudes towards vaccination and supported confidence with vaccination. (Table 3 provides a snapshot of student knowledge about and attitudes towards HPV and HPV vaccination across control and intervention groups.)

The qualitative component of the investigation revealed that students in the control group were primarily content to have the vaccine because of their trust in health professionals or the government, not because they had knowledge or understanding about HPV and/or HPV vaccination. In contrast, young people in the intervention group were primarily content to have the HPV vaccine because they had a sound knowledge and understanding about HPV and HPV vaccination.

The primary facilitators for educators teaching the intervention included having a comprehensive user guide, supplement, and user-friendly, age-appropriate resources. Educators also identified that experience and/or tertiary training teaching in health education was critical. The main barriers for teachers and school nurses in implementing the education intervention in schools were "time constraints".

"The concepts of expectations, observational learning, behavioural capacity, and self-efficacy informed by the three guiding behavioural theories..., appeared to promote the outcomes observed in this study." For example, the researchers suggest that observational learning, which occurred through students viewing the DVD and participating in class discussion, had a considerable impact on informing them and supported their beliefs about HPV and HPV vaccination.

Noting that some students participating in focus groups expressed limited knowledge about HPV-related cancers other than cervical cancer, the researchers recommend that, in future iterations of this education intervention, all young people be taught about all HPV-related diseases, regardless of their sex. Furthermore: "Ideally education about HPV, HPV vaccination and vaccine preventable diseases more broadly, should be provided throughout schooling to assist in maintaining good levels of knowledge and understanding. This may also have an impact on vaccination attitudes and decision-making for students who parent or have guardianship of children in the future."