Parents' Attitudes, Beliefs and Uptake of the School-based Human Papillomavirus (HPV) Vaccination Program in Jakarta, Indonesia - A Quantitative Study

"Parents who thought other people would approve HPV vaccine for their daughters were 7.3 times more likely to allow their daughters to be vaccinated..."

The Indonesian government began providing free human papillomavirus (HPV) vaccines for female students in grades 5-6 in Jakarta in 2016, followed by Yogyakarta in 2017 and Surabaya, Makassar, and Manado in 2018. The overall uptake of the vaccine as a result of these programmes is estimated to be over 90%. This study responds to the need to unpack what specific factors have contributed to this success before rolling the project out on a national scale. It examines parents' beliefs, attitudes, and intentions to allow their daughters to receive the HPV vaccine, as well as the uptake of the vaccine.

Data for this cross-sectional study were collected in Jakarta from September to November 2019. The questionnaire was based on the Theory of Planned Behaviour (TPB), which suggests that a person's behaviour (in this case, related to HPV vaccination) is predicted by their attitude, subjective norms, and perceived behavioural control. Participants included 484 parents or guardians of year 6 female students who were offered the free HPV vaccine in 33 primary schools. Analysis was done in two groups: the "decided" group (those parents who allowed or denied for their daughter to receive the HPV vaccination) and the "undecided" group (those parents who did not recall being approached about the HPV vaccine or forgot their response).

In the "decided" group, 295 (83.6%) parents allowed their daughters to receive the vaccination, while 58 (16.4%) parents refused it. In the "undecided" group, 49 (70%) parents reported a strong intention to allow their daughters to receive the vaccination; 21 (30%) had weak intention. Reflecting on the relatively low intention among the "undecided" group, the researchers note that Indonesia is the fourth-highest internet use rate worldwide (2021). Since health misinformation is commonly circulated on social media, it is likely that parents encountered incorrect or negative information about the HPV vaccines, which may have impacted their intentions to vaccinate. This finding suggests the need for additional research, especially qualitative studies, to explore where parents obtain their information about the HPV vaccine and what impact this had on their decision.

Per the TPB, attitude, subjective norms, and perceived behavioural control were shown to be significant predictors of HPV vaccine uptake when multilevel multivariate logistic regression analysis was undertaken. For instance, in the "decided" group, parents' decisions were significantly predicted by their positive attitude towards the vaccination in general (odds ratio (OR) 2.9; 95% confidence interval (CI) 1.31-6.71) and their belief that people around them would approve their decisions (OR 6.8; 95% CI 3.02-15.53). In contrast, parents who felt they had a high level of perceived behavioural control were more likely not to allow their daughters to receive the vaccine (OR 0.4; 95% CI 0.24-0.86). Those parents may not have perceived difficulties in arranging vaccination outside of the school-based immunisation programme; that is, they felt undeterred by finance, transport, or time constraints associated with taking their child elsewhere to be vaccinated. In the "undecided" group, attitude towards vaccination in general, subjective norms, and perceived behaviour control were not associated with parents' intentions to allow their daughters to receive the HPV vaccine.

In contrast, no independent variable was seen as a significant predictor for parents' intentions to vaccinate their daughter against HPV. No sociodemographic characteristic was significantly associated with parents' decisions or intentions regarding HPV vaccine for their daughters.

Overall, this study found that subjective norms had the strongest association with parents' decisions (OR = 7.3). In an earlier study, Fahy and Desmond (2010) showed that a stronger intention to vaccinate a daughter against HPV was related to the approval from peer groups and recommendations from healthcare professionals. Such findings may useful to develop targeted HPV vaccine health information campaigns, which should consider that "it is important to educate people about the HPV vaccine and cervical cancer, especially extended family and respected community members." Furthermore, in light of the fact that parents with high perceived behavioural control were more likely to refuse the vaccination and that "information about the HPV vaccine is easily accessible regardless of its accuracy, it is important to direct these parents to reliable information."

In conclusion: "There is a need for future qualitative research to explore parents' knowledge, attitude and beliefs about the HPV vaccine and the school-based vaccination program in Indonesia. Findings could be used to inform culturally appropriate targeted health information campaigns when expanding the HPV vaccination program across Indonesia."