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

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Title: 'Is It Like One of Those Infectious Kind of Things?' The Importance of Educating Young People about HPV and HPV Vaccination at School
Language: English
Authors: Davies, Cristyn, Skinner, Susan Rachel, Stoney, Tanya, Marshall, Helen Siobhan, Collins, Joanne, Jones, Jane, Hutton, Heidi, Parrella, Adriana, Cooper, Spring, McGeechan, Kevin, Zimet, Gregory
Source: Sex Education: Sexuality, Society and Learning. 2017 17(3):256-275.
Availability: Routledge. Available from: Taylor & Francis, Ltd. 530 Walnut Street Suite 850, Philadelphia, PA 19106. Tel: 800-354-1420; Tel: 215-625-8900; Fax: 215-207-0050; Web site: http://www.tandf.co.uk/journals
Peer Reviewed: Y
Page Count: 20
Publication Date: 2017
Document Type: Journal Articles
Reports - Research
Education Level: High Schools
Secondary Education
Descriptors: Sexually Transmitted Diseases, Immunization Programs, Foreign Countries, Randomized Controlled Trials, Intervention, Sex Education, Experimental Groups, Control Groups, Mixed Methods Research, Semi Structured Interviews, Focus Groups, Early Adolescents, High School Students
Geographic Terms: Australia
DOI: 10.1080/14681811.2017.1300770
ISSN: 1468-1811
Abstract: The National Human Papillomavirus (HPV) Vaccination Program in Australia commenced in 2007 for girls and in 2013 for boys, using the quadrivalent HPV [4vHPV] vaccine. In Australia, students are primarily vaccinated en masse, on school grounds, after parental/ guardian consent is obtained. Students most often receive little, or no, education at school about HPV or HPV vaccination prior to immunisation. There is also some uncertainty about where young people can and should obtain reliable information about the vaccine, outside of school. We conducted a cluster randomised controlled trial of a complex intervention in schools. This study aimed to improve: (1) student knowledge about HPV vaccination; (2) psycho-social outcomes and (3) vaccination uptake. In this paper, we briefly outline our educational intervention and discuss its implementation by educators including facilitators and barriers. We also discuss the study findings pertaining to student knowledge about HPV and HPV vaccination and their attitudes to vaccination across control and intervention schools. Study results showed students in intervention schools demonstrate greater knowledge and understanding of HPV and HPV vaccination. Greater knowledge and understanding of HPV and HPV vaccination appeared to promote positive attitudes towards vaccination and supported confidence with vaccination.
Abstractor: As Provided
Number of References: 44
Entry Date: 2017
Accession Number: EJ1138659
Database: ERIC
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  Value: <anid>AN0122658711;bf401may.17;2019Feb15.14:58;v2.2.500</anid> <title id="AN0122658711-1">‘Is it like one of those infectious kind of things?’ The importance of educating young people about HPV and HPV vaccination at school. </title> <p>The National Human Papillomavirus (HPV) Vaccination Program in Australia commenced in 2007 for girls and in 2013 for boys, using the quadrivalent HPV [4vHPV] vaccine. In Australia, students are primarily vaccinated en masse, on school grounds, after parental/guardian consent is obtained. Students most often receive little, or no, education at school about HPV or HPV vaccination prior to immunisation. There is also some uncertainty about where young people can and should obtain reliable information about the vaccine, outside of school. We conducted a cluster randomised controlled trial of a complex intervention in schools. This study aimed to improve: (<reflink idref="bib1" id="ref1">1</reflink>) student knowledge about HPV vaccination; (<reflink idref="bib2" id="ref2">2</reflink>) psycho-social outcomes and (<reflink idref="bib3" id="ref3">3</reflink>) vaccination uptake. In this paper, we briefly outline our educational intervention and discuss its implementation by educators including facilitators and barriers. We also discuss the study findings pertaining to student knowledge about HPV and HPV vaccination and their attitudes to vaccination across control and intervention schools. Study results showed students in intervention schools demonstrate greater knowledge and understanding of HPV and HPV vaccination. Greater knowledge and understanding of HPV and HPV vaccination appeared to promote positive attitudes towards vaccination and supported confidence with vaccination.</p> <p>Keywords: HPV; vaccination; education; knowledge; attitudes; Australia</p> <hd id="AN0122658711-2">Introduction</hd> <p>The National HPV Vaccination Program in Australia commenced school delivery in April 2007 for girls and February 2013 for boys, using the quadrivalent human papillomavirus (HPV) [4vHPV] vaccine. In Australia, students (aged 11–14 years) are primarily vaccinated as a group, on school grounds, after parental/guardian consent has been obtained. HPV vaccination is free of charge for students and is Commonwealth Government funded. Secondary schools distribute consent forms with an information brochure to all parents/guardians of eligible students. However, students most often receive little, or no, education 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.</p> <p>In this paper, we provide some brief background about HPV and HPV vaccination. We then discuss the limited knowledge and understanding many young people have about HPV and HPV vaccination based on our earlier research. Next, we outline our study aims and methodology, which included a cluster randomised controlled trial of a complex intervention in secondary schools and a process evaluation. We then briefly outline our theoretical framework, which was based on a broad psychosocial model. We also present our educational intervention and its relationship to the Australian (national and state-based) school curricula, and provide an overview of the implementation of our education intervention by educators (teachers and/or school nurses). Drawing on both quantitative and qualitative data, we discuss the findings related to student knowledge about HPV and HPV vaccination and their attitudes to vaccination. We also discuss the facilitators and barriers to teaching the education intervention in schools. Finally, we discuss the implications of these findings for schools, and specifically educators who teach health education to secondary students.</p> <hd id="AN0122658711-3">Background</hd> <p></p> <hd id="AN0122658711-4">HPV and HPV vaccination</hd> <p>HPV infection, if persistent, can cause cancers of the cervix, vulva, vagina, penis, anus and oropharynx. The two most prevalent cancer-causing genotypes are HPV16 (3.2% in healthy women) and HPV18 (1.4% in healthy women).[<reflink idref="bib1" id="ref4">1</reflink>] According to data from the Australian Institute of Health and Welfare (AIHW), in Australia in 2015, new cervical cancer cases affected 885 women, while 395 people were newly affected with anal cancer (AIHW [<reflink idref="bib4" id="ref5">4</reflink>]).[<reflink idref="bib2" id="ref6">2</reflink>] All cervical cancer is considered to be due to HPV infection (with HPV 16 and 18 causing at least 70%) (Trottier and Burchell [<reflink idref="bib42" id="ref7">42</reflink>]). At least 90% of anal cancer is associated with HPV (Trottier and Burchell [<reflink idref="bib42" id="ref8">42</reflink>]). HPV has been recognised as contributing to some cancers of the head and neck particularly cancers affecting the oropharynx (20–50% associated with HPV depending on study and site of cancer) which includes the base of the tongue, the tonsils and the upper throat (AIHW [<reflink idref="bib3" id="ref9">3</reflink>]; Trottier and Burchell [<reflink idref="bib42" id="ref10">42</reflink>]). All penile cancers are associated with HPV (mainly HPV 16) (Trottier and Burchell [<reflink idref="bib42" id="ref11">42</reflink>]). In 2005, there were 69 cases of penile cancer, which is rare, diagnosed in Australia (Grulich et al. [<reflink idref="bib22" id="ref12">22</reflink>]). The National HPV Vaccination Program in Australia uses the quadrivalent HPV [4vHPV] vaccine, which protects against two major HPV genotypes: 16 and 18 that are responsible for 70%–80% of cervical cancers (de Sanjosé et al. [<reflink idref="bib34" id="ref13">34</reflink>]), and also genotypes 6 and 11 which cause about 90% of genital warts (Garland et al. [<reflink idref="bib21" id="ref14">21</reflink>]).[<reflink idref="bib3" id="ref15">3</reflink>]</p> <p>In Australia, young people aged 11–14 years (year 7 or 8 in secondary school depending on jurisdiction) are vaccinated as part of the School-based Immunisation Program (SBIP). The HPV vaccine is offered alongside other vaccines in the national school vaccination programme (e.g. Diphtheria, Tetanus and Pertussis (DTaP) booster and varicella vaccines). The Australian National HPV Vaccination Program Register reported that for girls turning 15 years in 2015, 85.6% received HPV dose 1, 83% received HPV dose 2 and 77.4% received HPV dose 3 (National HPV Vaccination Program Register). National coverage has increased from an average of 73% for 3-doses in 2014 when this study was undertaken, to 77.4% in 2015. It is also worth noting that coverage varies across states, with some states such as South Australia and Western Australia (where this study was undertaken) and Tasmania reporting coverage lower than the national average. In boys, coverage is lower at a national average of 60% for 3-dose completion by 15 years in 2014. To achieve a comprehensive reduction in HPV disease burden at a population-level, vaccination uptake needs to be consistently high (Regan et al. [<reflink idref="bib30" id="ref16">30</reflink>]; Tabrizi et al. [<reflink idref="bib41" id="ref17">41</reflink>]; Drolet et al. [<reflink idref="bib19" id="ref18">19</reflink>]; Skinner et al. [<reflink idref="bib38" id="ref19">38</reflink>]).[<reflink idref="bib4" id="ref20">4</reflink>] HPV vaccines are now recommended as part of vaccination programmes for girls in many countries (Markowitz et al. [<reflink idref="bib26" id="ref21">26</reflink>]), and more recently some countries have extended this recommendation to boys. Implementation of HPV vaccination programmes varies considerably by country, as do vaccination coverage levels (Drolet et al. [<reflink idref="bib19" id="ref22">19</reflink>]; Wigle, Fontenot, and Zimet [<reflink idref="bib44" id="ref23">44</reflink>]). Generally, school-based programmes tend to have higher coverage than non-school based programmes (Marshall et al. [<reflink idref="bib28" id="ref24">28</reflink>]).</p> <hd id="AN0122658711-5">Limited knowledge and understanding about HPV and HPV vaccination</hd> <p>Many young people have limited or no understanding of the vaccines they receive, including the HPV vaccine, or the diseases they are intended to prevent (Cooper Robbins, Bernard, McCaffery, Garland, et al. [<reflink idref="bib11" id="ref25">11</reflink>]; Bowyer et al. [<reflink idref="bib6" id="ref26">6</reflink>]; Davies and Burns [<reflink idref="bib15" id="ref27">15</reflink>]; Burns and Davies [<reflink idref="bib8" id="ref28">8</reflink>]; Skinner et al. [<reflink idref="bib38" id="ref29">38</reflink>]; Kelly-Hanku et al. [<reflink idref="bib24" id="ref30">24</reflink>]). 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 (Cooper Robbins, Bernard, McCaffery, and Skinner [<reflink idref="bib12" id="ref31">12</reflink>]; Burns and Davies [<reflink idref="bib8" id="ref32">8</reflink>]). Australian girls offered the vaccine as part of the school programme had limited, or no understanding about HPV, HPV vaccination, their future risk of cervical cancer and other sexually transmitted infections (Cooper Robbins, Bernard, McCaffery, et al. [<reflink idref="bib12" id="ref33">12</reflink>]; Burns and Davies [<reflink idref="bib8" id="ref34">8</reflink>]; Cooper et al. [<reflink idref="bib13" id="ref35">13</reflink>]). Knowledge of HPV and vaccination has been found to be even lower in Australian boys than girls (Agius [<reflink idref="bib2" id="ref36">2</reflink>]). Poor understanding about HPV and the HPV vaccine has also been linked to heightened anxiety on vaccination day (Cooper Robbins, Bernard, McCaffrey, et al. [<reflink idref="bib12" id="ref37">12</reflink>]; Burns and Davies [<reflink idref="bib8" id="ref38">8</reflink>]).</p> <p>Informed young people are in a better position to make decisions about their health and well-being (Davies and Burns [<reflink idref="bib15" id="ref39">15</reflink>]; Burns and Davies [<reflink idref="bib8" id="ref40">8</reflink>]). Young people are unlikely to learn about HPV and HPV vaccination without structured and effective education (Cooper et al. [<reflink idref="bib13" id="ref41">13</reflink>]). Expecting parents/guardians to educate young people is also unlikely to be effective as their own knowledge about HPV and HPV vaccination can also be very limited (Marshall et al. [<reflink idref="bib27" id="ref42">27</reflink>], [<reflink idref="bib28" id="ref43">28</reflink>]), and, as with sex education more broadly (Davies and Robinson [<reflink idref="bib16" id="ref44">16</reflink>]; Robinson and Davies [<reflink idref="bib33" id="ref45">33</reflink>], [<reflink idref="bib31" id="ref46">31</reflink>]) they also experience barriers such as embarrassment about discussing the sexually transmitted nature of the virus with their child (Cooper Robbins et al. [<reflink idref="bib10" id="ref47">10</reflink>]). Young people's access to accurate, research-based information about HPV and HPV vaccination is a critical component of their sex education, contributing to healthy sexual citizenship and the development of their sexual literacy (Davies and Robinson [<reflink idref="bib16" id="ref48">16</reflink>]; Illes [<reflink idref="bib23" id="ref49">23</reflink>]; Robinson [<reflink idref="bib32" id="ref50">32</reflink>]). They have a right to information that they can understand about their health and health care, which is an ethical imperative to ensure informed consent (Children's Hospitals Australasia's [<reflink idref="bib9" id="ref51">9</reflink>]).</p> <hd id="AN0122658711-6">Study aims</hd> <p>Against the background described above, this study aimed to improve: (<reflink idref="bib1" id="ref52">1</reflink>) student knowledge about HPV vaccination; (<reflink idref="bib2" id="ref53">2</reflink>) psycho-social outcomes and (<reflink idref="bib3" id="ref54">3</reflink>) vaccination uptake. We discuss our findings for our first study aim, and attitudes to HPV vaccination, which is a component of our second study aim.</p> <hd id="AN0122658711-7">Methods</hd> <p>We conducted a multi-centre cluster randomised controlled trial (RCT) of a complex intervention in 40 secondary schools with 6965 secondary students from 2012 to 2014 (Skinner et al. [<reflink idref="bib37" id="ref55">37</reflink>]). In medicine, RCTs are considered the most rigorous way of determining whether a cause-effect relation exists between treatment and outcome, and for assessing the cost-effectiveness of a treatment (Sibbald and Roland [<reflink idref="bib36" id="ref56">36</reflink>]). Generally, the unit of control in a RCT is an individual subject (patient). In a cluster RCT, groups of subjects (such as schools) are randomised to receive an intervention or act as a control (usual practice) rather than individual subjects (such as students) (Sibbald and Roland [<reflink idref="bib36" id="ref57">36</reflink>]). See Figure 1.</p> <p>Graph: Figure 1. Study design.</p> <hd id="AN0122658711-8">Sample</hd> <p>Forty schools were randomly allocated to intervention (21 schools, 3806 students) or control (19 schools, 3159 students). Intervention schools received the complex intervention which included an intervention for young people (education and distraction); a shared decisional support tool for parents and young people and logistical strategies (consent form return strategies, in-school supplementary HPV vaccination team visits, targeting students who have missed a dose of the vaccine, and vaccination-day guidelines).</p> <hd id="AN0122658711-9">Setting</hd> <p>The study was conducted in Western Australia (WA) and South Australia (SA) with schools stratified by Government, Catholic, and Independent sectors and geographical location.</p> <hd id="AN0122658711-10">Participants</hd> <p>Students in their first year of high school (year 8 in participating states), key school personnel (teachers, principals, school nurses), immunisation nurses and parents/guardians participated in the study. In 2013, boys were vaccinated in year 9 as part of the HPV catch-up programme and participated in our study in selected schools.</p> <hd id="AN0122658711-11">Recruitment</hd> <p>A stratified random sample of schools was invited to participate in the HPV.edu study. Those who accepted were then randomly allocated to intervention or control. Schools were recruited via a study invitation letter sent to the school principal with telephone follow-up by study staff. Purposive sampling across school sectors and intervention and control groups (5 control, 6 intervention) was used to subsequently recruit 11 case study schools from the study sample for the qualitative component of the study.</p> <hd id="AN0122658711-12">Intervention</hd> <p>Schools that were randomly allocated to the intervention group were provided with study educational materials (see Education Resources about HPV and HPV vaccination below) and were advised to use the materials at around the time the consent forms were distributed and before the first dose of vaccine was administered. Each educator (teacher and/or school nurse) was invited to complete a log documenting lesson type, student year group, number of students in attendance at the HPV.edu lesson, sex of students, lesson time spent educating students about HPV and HPV vaccination, educational resources used, number of students that received the magazine, number of students that undertook the student questionnaire, kinds of questions asked by students about HPV and HPV vaccination, educator confidence with responding to student questions, and educator comments and suggestions regarding the education resources. Control schools followed usual practice, without these educational materials.</p> <hd id="AN0122658711-13">Theoretical framework</hd> <p>The conceptualisation and design and of our 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, to inform the intervention development (Wight, Abraham, and Scott [<reflink idref="bib43" id="ref58">43</reflink>]). We also drew on widely recognised theories of behaviour change, including the Health Belief Model (HBM) (Strecher and Rosenstock [<reflink idref="bib40" id="ref59">40</reflink>]), the Theory of Planned Behaviour (TPB) (Ajzen [<reflink idref="bib5" id="ref60">5</reflink>]) and Social Cognitive Theory (Luszczynska and Schwarzer [<reflink idref="bib25" id="ref61">25</reflink>]), which have been used successfully in health promotion programmes including the promotion of immunisation. For a more detailed description of the relationship between behaviour change theories and our education resources, please see our intervention constructs and strategies for young people for the education intervention (Cooper et al. [<reflink idref="bib13" id="ref62">13</reflink>]).</p> <hd id="AN0122658711-14">Data collection</hd> <p>Our mixed methods evaluation design was implemented to explore, in-depth, possible mechanisms for any observed effect of the intervention on knowledge of HPV and HPV vaccination, as well as change in a range of psychosocial outcomes, such as fear and anxiety relating to HPV vaccination and HPV vaccination uptake. The study included a quantitative evaluation (validated student survey) 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). The student survey, called HPV Adolescent Intervention Questionnaire (HAVIQ) was undertaken pre-dose 1, 2 and 3 of the HPV vaccine. Interviews and focus groups were undertaken post-dose 2 until after dose 3 of the vaccine. We also developed fidelity logs for teachers undertaking the education intervention with students, for immunisation nurses on vaccination day, and for school personnel supervising vaccination day.</p> <hd id="AN0122658711-15">Data analysis</hd> <p>We developed and validated the HAVIQ to determine changes in knowledge about HPV and vaccination. Items in this measure were developed from existing HPV vaccine questionnaires, the results of our own preliminary qualitative research, and an expert panel of academics working in related fields. A short series of factual questions were asked of students, relating to information that had been provided in the educational materials, with options of agree/ disagree/ don't know. We collapsed the incorrect response with don't know to dichotomise the response for each item for each student. We then calculated a mean percentage of correct responses for students in intervention schools, and compared this to the mean percentage of correct responses for students in control schools. Statistical tests included two-sample t-tests with appropriate adjustment for clustering.[<reflink idref="bib5" id="ref63">5</reflink>]</p> <p>We also conducted semi-structured focus groups and interviews, which were digitally recorded, transcribed verbatim, and de-identified. For students, focus group discussions focused on: knowledge and understanding about HPV and HPV vaccination, HPV vaccine decision-making and HPV vaccination experience on the day. In addition, intervention groups were asked about the usefulness of HPV.edu education resources. Thematic analysis was used to code the data in NVivo9 (qualitative data computer software, QSR Ltd, Australia) and to analyse the data. Thematic analysis is a method for identifying, analysing and reporting patterns (themes) within data (Braun and Clarke [<reflink idref="bib7" id="ref64">7</reflink>]). Inductive (themes emerging from the data) and deductive (theoretical and analytical themes emerging from the research questions) were employed. Blinded analysis was undertaken across the cohorts to ensure objectivity; that is, the first author did not know which participants were from an intervention or control school during the process of coding and analysis.</p> <hd id="AN0122658711-16">Advisory Board</hd> <p>The study Advisory Board included representatives from the Government, Catholic and Independent education sectors and from health department and immunisation teams in both study jurisdictions. The Advisory Board provided input on all aspects of the study including resources (content and design), school recruitment, intervention implementation and dissemination of study findings.</p> <hd id="AN0122658711-17">Ethics and informed consent</hd> <p>We obtained ethical approval from all relevant bodies across our research sites. This included the Department of Health WA Human Research Ethics Committee (HREC), Women's and Children's Hospital (WCHN) HREC, relevant WA and SA government authorities and approval from the University of Sydney. WA and SA approved the conduct of the intervention in schools, without a requirement for parental consent. For student participation in the survey, parental/guardian opt-out consent was approved by all relevant SA authorities, while in WA we were required to obtain active parental/guardian consent, in addition to the requirement for student assent in all schools. Active parental/guardian consent and student assent was required for participation in student focus groups.</p> <hd id="AN0122658711-18">Education resources about HPV and HPV vaccination</hd> <p>The education intervention consisted of an educator guide and supplement with interactive lessons,[<reflink idref="bib6" id="ref65">6</reflink>] a DVD/film, a website[<reflink idref="bib7" id="ref66">7</reflink>] (<ulink href="http://takechargehpv.org">http://takechargehpv.org</ulink>), an app available on mobile devices across platforms, a magazine[<reflink idref="bib8" id="ref67">8</reflink>] and distraction/relaxation methods to be used prior to and during vaccination.[<reflink idref="bib9" id="ref68">9</reflink>] Further information on the development of the education intervention is detailed in a separate publication (Cooper et al. [<reflink idref="bib13" id="ref69">13</reflink>]). Briefly, the guide and supplement provided educators with background information regarding the development of the education resources, their relevance to the Australian curriculum and suggested lesson plans with 9 in-class activities linked to the DVD chapters. Five activities focused on HPV and vaccination,[<reflink idref="bib10" id="ref70">10</reflink>] two activities on the decision-making process,[<reflink idref="bib11" id="ref71">11</reflink>] one activity on the practical aspects of vaccination day[<reflink idref="bib12" id="ref72">12</reflink>] and one summary activity. The 18-min DVD consisted of seven chapters. Four of these chapters focused on HPV and vaccination,[<reflink idref="bib13" id="ref73">13</reflink>] one chapter covered the decision-making process,[<reflink idref="bib14" id="ref74">14</reflink>] one chapter addressed practical aspects of vaccination day[<reflink idref="bib15" id="ref75">15</reflink>] and the final chapter summarised key information. We designed the DVD to be screened in an interactive way during class time to promote discussion between students and their teacher/school nurse. The app also contained the DVD chapters, the text from the DVD chapters in summary form, an e-copy of the magazine, and distraction/relaxation methods. Schools were provided with the HPV.edu study website address and at least one hard copy of the magazine and decisional support tool per student.[<reflink idref="bib16" id="ref76">16</reflink>]</p> <hd id="AN0122658711-19">Relevance to Australian State and National Curricula</hd> <p>The education resources for study intervention schools were designed to meet the curriculum guide and outcomes for Physical Health and Education in South Australia and Western Australia. We supplied educators with a user guide and supplement. We also consulted with education professionals from The Australian Curriculum, Assessment and Reporting Authority (ACARA) to ensure that the resources were consistent with the outcomes of the National Curriculum. Our education intervention focused on developing health literacy, consistent with a strengths-based approach, recognising that schools are key settings for developing health-related knowledge and skills (ACARA [<reflink idref="bib1" id="ref77">1</reflink>]).[<reflink idref="bib17" id="ref78">17</reflink>]</p> <p>In Western Australia, our educational resources addressed the 'Knowledge and Understandings' (includes promoting well-being), and 'Self-management Skills' (includes self-understanding and decision-making) phases of curriculum development in the Health and Physical Education Learning Area Statement (Curriculum Council [<reflink idref="bib14" id="ref79">14</reflink>]). Within the year 8 syllabus, HPV.edu was designed to meet the requirements of 'Contributing to Health and Active Communities', a strand focused on health promotion activities which target relevant health issues for young people and ways to prevent them (School Curriculum and Standards Authority [<reflink idref="bib35" id="ref80">35</reflink>]). In South Australia, the educator's guide and resources were designed to meet the South Australian Curriculum and SACSA Companion Document SERIES: R-10 Health and Physical Education Teaching Resource (DECS [<reflink idref="bib18" id="ref81">18</reflink>]), and the South Australian Curriculum, Standards and Accountability Framework—Strand: Health of Individuals and Communities (DECS [<reflink idref="bib17" id="ref82">17</reflink>]).</p> <hd id="AN0122658711-20">Implementation of the education intervention</hd> <p>Prior to the commencement of the intervention, study staff introduced the resources to educators in intervention schools, and provided advice about how they were intended to be used. Specific resources were used at the discretion of individual educators, who reported their selection via the educator logs. Overall 71 educator logs[<reflink idref="bib18" id="ref83">18</reflink>] 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 five 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). Individual schools were classified as low (utilising 0–6 resources), moderate (utilising 7–12 resources) or high (utilising 13–18 resources) implementers of the educational intervention. Five schools were high implementers, 13 schools were moderate implementers and 3 were low implementers. We understand that the number of resources used by intervention schools does not necessarily correspond to the <emph>quality</emph> of teaching and learning that took place in the classroom, but rather Table 1 below represents the level of implementation of the education resources.</p> <p>Table 1. Number and type of education resources used by intervention schools.</p> <p> <ephtml> <table><thead><tr valign="top"><td>Educational resource</td><td>Number of schools<xref ref-type="table-fn" rid="EN0028">a</xref></td></tr></thead><tbody><tr valign="top"><td>DVD chapter: What is HPV</td><td char=".">21</td></tr><tr valign="top"><td>DVD chapter: What is HPV vaccination</td><td char=".">20</td></tr><tr valign="top"><td>DVD chapter: Boys and HPV<xref ref-type="table-fn" rid="EN0029">b</xref></td><td char=".">20</td></tr><tr valign="top"><td>Magazine</td><td char=".">20</td></tr><tr valign="top"><td>DVD chapter: Vaccination on the Day</td><td char=".">19</td></tr><tr valign="top"><td>DVD chapter: HPV decision-making</td><td char=".">18</td></tr><tr valign="top"><td>DVD chapter: Vaccination in the Future</td><td char=".">18</td></tr><tr valign="top"><td>Website</td><td char=".">14</td></tr><tr valign="top"><td>In- class activity: Crossword puzzle</td><td char=".">12</td></tr><tr valign="top"><td>In- class activity: Talk with your parents</td><td char=".">10</td></tr><tr valign="top"><td>In-class activity: HPV Bingo</td><td char=".">8</td></tr><tr valign="top"><td>In- class activity: The decision-making process</td><td char=".">6</td></tr><tr valign="top"><td>In-class activity: The decision-making process</td><td char=".">6</td></tr><tr valign="top"><td>In- class activity: Meditation Exercise</td><td char=".">4</td></tr><tr valign="top"><td>In-class activity: Educate the Public</td><td char=".">4</td></tr><tr valign="top"><td>In-class activity: Summary</td><td char=".">4</td></tr><tr valign="top"><td>In- class activity: Matching Game</td><td char=".">3</td></tr><tr valign="top"><td>DVD chapter: Recap</td><td char=".">3</td></tr></tbody></table> </ephtml> </p> <ulist> <item>28 Each resource was used in at least one teaching session in each school.</item> <item>29 We developed a chapter for boys based on feedback from the study Advisory Board given that the vaccine became part of the SBIP from 2013 to clarify relevance of the HPV vaccine for this population. Information relevant to girls had already been incorporated into earlier DVD chapters.</item> </ulist> <p>Schools used an average of 10 resources (range 2 to 15). The DVD and the magazine were most used by educators. Each of the 21 intervention schools screened at least one chapter of the DVD, and 20 schools distributed the magazine to students. Fourteen schools used the HPV.edu study website and 16 schools used at least one in-class activity (averaging 2.7 activities per school, range 0 to 7). The crossword (12/21) and 'talk with your parents' (10/21) were the most used in-class activities.</p> <hd id="AN0122658711-21">Quantitative data findings</hd> <p>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 (Table 2). This meant that students in intervention schools had 32 percentage points more correct responses; this was highly statistically significant. 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. Hence, at 6 months after the education, students in intervention schools had 20 percentage points more correct responses, on average, than students in control schools, again highly statistically significant.</p> <p>Table 2. Percent of knowledge questions answered correctly.</p> <p> <ephtml> <table><thead><tr valign="top"><td>Time</td><td>Group</td><td>Number of schools</td><td>Number of students with valid knowledge scores</td><td>Mean percent answered correctly (%)</td><td>Difference (95% CI)<xref ref-type="table-fn" rid="TFN0001">a</xref></td><td>P-value<xref ref-type="table-fn" rid="TFN0001">a</xref></td></tr></thead><tbody><tr valign="top"><td>Pre dose 1</td><td>Intervention</td><td char=".">21</td><td char=".">1641</td><td char=".">65</td><td char=".">32% (27%, 36%)</td><td char="."><0.0001</td></tr><tr valign="top"><td /><td>Control</td><td char=".">19</td><td char=".">1357</td><td char=".">33</td><td /><td /></tr><tr valign="top"><td>Pre dose 3</td><td>Intervention</td><td char=".">21</td><td char=".">1677</td><td char=".">53</td><td char=".">20% (17%, 24%)</td><td char="."><0.0001</td></tr><tr valign="top"><td /><td>Control</td><td char=".">19</td><td char=".">1479</td><td char=".">32</td><td /><td /></tr></tbody></table> </ephtml> </p> <p>1 Adjusted for year, state, sector, co-educational status and clustering of students within schools.</p> <hd id="AN0122658711-22">Qualitative data findings</hd> <p>We now present our results for the student focus groups pertaining to knowledge and attitudes about HPV and HPV vaccination. Table 3 provides a snapshot of student knowledge about and attitudes towards HPV and HPV vaccination across control and intervention groups. There were marked differences in knowledge and understanding between control and intervention students. Table 4 provides demographic data from the case study schools that participated in the qualitative study. Most of the schools in our sample had higher than average Index of Community Socio-Educational Advantage (ICSEA) ranking.[<reflink idref="bib19" id="ref84">19</reflink>] We expected that schools with lower than average ICSEA rankings could also benefit from our education intervention as some control schools may have reduced agency to access high quality, research-based information about HPV and HPV vaccination to educate relevant students.</p> <p>Table 3. Snapshot of student knowledge and understanding of HPV and HPV vaccination.</p> <p> <ephtml> <table><thead><tr valign="top"><td>Topic</td><td>Control</td><td>Intervention</td></tr></thead><tbody><tr valign="top"><td>Knowledge about HPV</td><td>Limited /no knowledge: 'I'm not sure', 'Is it like one of those infectious kind of things?', 'Never heard it before', 'I have no idea'</td><td>Good knowledge: 'It causes cancer', 'Boys and girls can get it'</td></tr><tr valign="top"><td>Diseases caused by HPV</td><td>Students were less confident: 'Is it like vaginal cancer?' [Is it something] 'to do with the reproductive system or something like that?' </td><td>Students were confident: 'It can cause cervical cancer', '[It can cause] genital warts', '[It can cause] genital cancer'</td></tr><tr valign="top"><td>Transmission of HPV</td><td>Some students understood transmission through sexual contact. Others believed it was an 'airborne disease', or transmitted by sharing food and drinks, coughing and sneezing, or through saliva, or blood, or genetic</td><td>Most students understood that mode of transmission was through sexual contact </td></tr><tr valign="top"><td>Doses required to complete quadrivalent HPV vaccine</td><td>Students had varied responses: some thought that 2 [<italic>sic</italic>.] doses were required</td><td>Students knew 3 doses were required</td></tr><tr valign="top"><td>How the HPV vaccine works in the body</td><td>Students generally had limited/inconsistent/incorrect understanding</td><td>Students had good if not perfect understanding: the vaccine 'injects small doses of HPV into your body and then like it teaches your body how to like fight it off.'</td></tr><tr valign="top"><td>Reason for getting HPV vaccine</td><td>Got vaccine because of trust in government/health professionals: 'I don't think there would be much of a risk with taking vaccinations because the people who made them know what they are doing.'</td><td>Got vaccine because of its benefits: 'One of the reasons I wanted to get it was just like I know in the future I am like protected by it.' </td></tr><tr valign="top"><td>Attitudes to HPV vaccination and the SBIP</td><td>Generally positive, but had limited knowledge and therefore concerns: 'Like what if something happens' </td><td>Most were positive because of knowledge/understanding. Would encourage peers to get vaccine </td></tr><tr valign="top"><td>Cervical screening</td><td>Did not mention cervical screening</td><td>Many girls knew that they still had to get Pap test: 'Oh I'm pretty sure it doesn't completely stop it [HPV] but if you keep going to get your Pap smear thingy that can tell you if you have it [HPV] or not.'</td></tr><tr valign="top"><td>Where students learned about the HPV vaccine</td><td>Some said they learned about HPV vaccine at school, but also the Internet; friends; the news media; parents. Information was inconsistent: 'Yeah, we got told about it ...' and '[...]I didn't get told anything.'</td><td>Learned about HPV vaccine from educators at school: 'we had a lot of lessons about it', and from their parents</td></tr><tr valign="top"><td>Misinformation</td><td>Some thought it protected against HIV/AIDS: '...I am not sure if this is right, but it could also prevent AIDS maybe.'</td><td>Before intervention, some thought the vaccine protected against HIV/AIDS: '... about HPV I'm like, oh do you mean HIV? And they [the educator] go no, HPV'</td></tr><tr valign="top"><td>Communication with parents/guardians about HPV vaccine</td><td>Many students did not discuss whether or not to have the vaccine with their parents/guardians</td><td>Some students discussed HPV vaccine with parents after education: <bold><italic>'</italic></bold>I just told my parents and then they didn't want me to do it at first but I told them like what it does and that it could prevent'</td></tr></tbody></table> </ephtml> </p> <p>Table 4. HPV.edu school demographic data from qualitative study.</p> <p> <ephtml> <table><thead><tr valign="top"><td>School No.</td><td>State</td><td>Group</td><td>Year</td><td>Sector</td><td>School type</td><td>ICSEA<xref ref-type="table-fn" rid="EN0030">a</xref></td><td>No. of focus groups</td><td>Participating students</td><td>Males %</td><td>Females %</td></tr></thead><tbody><tr valign="top"><td>201</td><td>WA</td><td>Control</td><td>2013</td><td>Independent</td><td>Boys</td><td char=".">1191</td><td char=".">1</td><td char=".">3</td><td char=".">100</td><td char=".">0</td></tr><tr valign="top"><td>202</td><td>WA</td><td>Intervention</td><td>2013</td><td>Independent</td><td>Boys</td><td char=".">1191</td><td char=".">2</td><td char=".">15</td><td char=".">100</td><td char=".">0</td></tr><tr valign="top"><td>218</td><td>WA</td><td>Intervention</td><td>2014</td><td>Government</td><td>Co-ed</td><td char=".">1047</td><td char=".">2</td><td char=".">10</td><td char=".">40</td><td char=".">60</td></tr><tr valign="top"><td>220</td><td>WA</td><td>Control</td><td>2014</td><td>Government</td><td>Co-ed</td><td char=".">1047</td><td char=".">3</td><td char=".">20</td><td char=".">35</td><td char=".">65</td></tr><tr valign="top"><td>223</td><td>WA</td><td>Control</td><td>2014</td><td>Catholic</td><td>Co-ed</td><td char=".">994</td><td char=".">3</td><td char=".">18</td><td char=".">33</td><td char=".">67</td></tr><tr valign="top"><td>224</td><td>WA</td><td>Intervention</td><td>2014</td><td>Catholic</td><td>Co-ed</td><td char=".">1032</td><td char=".">2</td><td char=".">10</td><td char=".">20</td><td char=".">80</td></tr><tr valign="top"><td>113</td><td>SA</td><td>Control</td><td>2014</td><td>Government</td><td>Co-ed</td><td char=".">1074</td><td char=".">1</td><td char=".">11</td><td char=".">55</td><td char=".">45</td></tr><tr valign="top"><td>110</td><td>SA</td><td>Intervention</td><td>2014</td><td>Government</td><td>Co-ed</td><td char=".">1009</td><td char=".">0</td><td char=".">0<xref ref-type="table-fn" rid="EN0031">b</xref></td><td char=".">0</td><td char=".">0</td></tr><tr valign="top"><td>115</td><td>SA</td><td>Intervention</td><td>2014</td><td>Independent</td><td>Co-ed</td><td char=".">1068</td><td char=".">1</td><td char=".">9</td><td char=".">56</td><td char=".">44</td></tr><tr valign="top"><td>107</td><td>SA</td><td>Control</td><td>2014</td><td>Independent</td><td>Co-ed</td><td char=".">1162</td><td char=".">0</td><td char=".">0<xref ref-type="table-fn" rid="EN0031">b</xref></td><td char=".">0</td><td char=".">0</td></tr><tr valign="top"><td>104</td><td>SA</td><td>Intervention</td><td>2013</td><td>Independent</td><td>Girls</td><td char=".">1175</td><td char=".">1</td><td char=".">10</td><td char=".">0</td><td char=".">100</td></tr><tr valign="top"><td>103</td><td>SA</td><td>Control</td><td>2013</td><td>Independent</td><td>Girls</td><td char=".">1065</td><td char=".">1</td><td char=".">5</td><td char=".">0</td><td char=".">100</td></tr></tbody></table> </ephtml> </p> <ulist> <item>30 ICSEA refers to Index of Community Socio-Educational Advantage. ICSEA is a scale, which allows for fair and reasonable comparisons among schools with similar students. ICSEA is set at an average of 1000, which can be used as a benchmark. The lower or higher the ICSEA value, the lower or higher the level of educational advantage of students who attend this school.</item> <item>31 Observations were conducted in these case study schools, but not focus groups as it was not convenient for the school.</item> </ulist> <hd id="AN0122658711-23">Facilitators and barriers to implementing the education intervention</hd> <p>The primary facilitators for educators teaching the intervention included having a comprehensive user guide, supplement and user-friendly, age-appropriate resources:</p> <p>I would definitely use the resources again. Um, I would definitely show the DVD, definitely. Um and I love the magazine so I would hope that we could give out the magazine again (School nurse, female, Year 8, Government co-educational school).</p> <p>I think in the classroom the actual programme, I found was really good. My girls although they were a bit giggly they really enjoyed it and I think they understood then why they are actually having it, otherwise they wouldn't have had any idea (Health and Physical Education teacher 1, female, Year 8, Independent School).</p> <p>Yeah, so I certainly enjoyed it, I was happy [that] I had a resource there to follow to give me some guidelines; I think that helped (Health and Physical Education, teacher 2, female, Year 8, Independent School).</p> <p>I thought the DVD was really good, you know [...] because it was informative and it did answer a lot of questions. It actually helped clear it up in my mind too a little, you know, and I felt more comfortable teaching it (Health and Physical Education teacher 1, Year 8, Independent School).</p> <p>Educators also identified that experience and/or tertiary training teaching in health education was critical: 'I think it helps that we're PE [Physical Education] teachers and [...] have taught a lot of health'. Other teachers commented that their background in science assisted them. Significantly, teachers/school nurses commented that the Teacher/school nurse user guide, supplement and resources would assist less experienced colleagues: 'I think inexperienced teachers would find that sort of framework helpful'. Most educators felt that, combined with their own knowledge and experience, the resources allowed them to effectively respond to student questions about HPV, HPV vaccination and related sexual health matters: 'I felt comfortable with and had the knowledge and was able to answer [students' questions] well'.</p> <p>The main barriers for teachers and school nurses in implementing the education intervention in schools were 'time constraints'. In this study, schools were asked to teach students about HPV and HPV vaccination before the first dose of HPV vaccine was administered to students, which meant that some schools had a short lead in time to organise when and in what subject area the education was taught. While schools attempted to teach students the intervention during a Health class, or during another class period to keep class sizes to a minimum, some schools elected to teach the education intervention to large groups for logistical reasons, thus limiting the opportunities for a more interactive learning experience. While some teachers/ school nurses would have liked more lesson time to teach about HPV and HPV vaccination, all educators were able to use the resources provided to fit within the class lesson time provided. In addition, because the education intervention was compliant with the sexual health and relationships (SHR) Health curriculum, some teachers switched SHR education and a unit of study scheduled earlier in the year. The education intervention demonstrated that educators benefited from having access to training and to research-based, accurate information about HPV and HPV vaccination both for their own professional development, and to teach their students (Spratt et al. [<reflink idref="bib39" id="ref85">39</reflink>]).</p> <hd id="AN0122658711-24">Discussion and recommendations: implications for educators</hd> <p>This is a world-first RCT study to examine the impact of an educational intervention on knowledge about and attitudes towards HPV and HPV vaccination amongst young people in a mass SBIP (School Based Immunisation Program). We found that our education intervention was easy to implement, and was widely used by teachers and school nurses as part of the school curriculum during scheduled school time. Our education intervention, on average, resulted in students significantly increasing their knowledge and understanding of HPV and HPV vaccination. They also reported improved attitudes to the vaccination experience after education.</p> <p>Our findings also have important implications for young people's understandings about future cervical cancer and HPV-related cancer prevention, improved knowledge, attitudes and skills around vaccination, improved knowledge and understanding of safe sex practices, and playing an active role in decisions about their own health and well-being. 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 (State and National), when they are supported by an educator user guide, supplement and user-friendly, age appropriate educational resources.</p> <p>Our qualitative data provided a more nuanced understanding of how the education impacted on young people's understandings. Students in control groups had a limited understanding about HPV and HPV vaccination and in some cases students had misinformation about HPV and the HPV vaccine. Conversely, young people in intervention groups had good knowledge and understanding about HPV vaccination. Students in intervention groups demonstrated more comprehensive knowledge about HPV and HPV vaccination than students in control groups. While the questionnaire showed some attenuation of knowledge, although still a marked difference between intervention and control, it would be ideal to provide further education to support student knowledge and understanding about HPV and HPV vaccination and positively impact their attitudes and vaccination self-efficacy.</p> <p>Many young people in the control group were not sure whether they had completed the HPV vaccine course, and some had no understanding of whether they had been vaccinated against HPV and the implications of this decision.[<reflink idref="bib20" id="ref86">20</reflink>] 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 any knowledge or understanding about HPV and/or HPV vaccination nor its implications for them and herd immunity.[<reflink idref="bib21" id="ref87">21</reflink>] However, 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. This knowledge and understanding appeared to promote positive student attitudes towards the HPV vaccine and self-efficacy on vaccination day more broadly.</p> <p>With respect to the outcome of knowledge gain, intervention students' core beliefs were informed by improved knowledge and understanding, which led them to expectations[<reflink idref="bib22" id="ref88">22</reflink>] that they would be protected by the HPV vaccine, whereas in the control group, students' expectations about protection were simplistic, guided by pre-existing beliefs that authorities must be trusted. These findings illustrate the impact of the three guiding behavioural theories particularly regarding the concept of expectations (Cooper et al. [<reflink idref="bib13" id="ref89">13</reflink>]). In addition, observational learning[<reflink idref="bib23" id="ref90">23</reflink>] (Cooper et al. [<reflink idref="bib13" id="ref91">13</reflink>]), 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. Many students in the intervention group used their knowledge and understanding to moderate their fear, anxiety or concerns about vaccination-related discomfort and pain. The education intervention positively impacted their attitudes and behaviour on vaccination day, therefore demonstrating both student behavioural capacity[<reflink idref="bib24" id="ref92">24</reflink>] and self-efficacy.[<reflink idref="bib25" id="ref93">25</reflink>]</p> <p>Some students' participating in focus groups expressed limited knowledge about other HPV-related cancers (other than cervical cancer).[<reflink idref="bib26" id="ref94">26</reflink>] In future iterations of our education intervention, we recommend that all young people be taught about other HPV-related cancers, which will also help to assist in clarifying the relevance of the HPV vaccine for boys (including the effects of herd immunity and the reduction of disease burden). It is important that all young people be taught about all HPV-related diseases regardless of their sex. Denying students an opportunity to learn about HPV and HPV vaccination has implications for their human rights as well as future health behaviours. These include, but are not limited to, young people's role and attitudes in decision-making about their health and well-being and that of their future partners and family members, making informed decisions about immunisation, safe sex practices, and where relevant, participation in cervical screening in the future. Our findings indicate that young people's understandings in the control group were unlikely to promote these behaviours.</p> <p>Our study showed that it is feasible to educate students in schools about HPV and HPV vaccination, preferably in health education classes, when using a research-based user guide, supplement and user-friendly educational resources to support educators. In our study, teachers and school nurses were restricted by time. However, in the future, educators could be informed about our educational package before the school year commences, allowing adequate preparation time. Educators found many of the resources useful, especially the DVD and student take-home magazine, in effectively communicating knowledge about, and promoting an understanding of, HPV and HPV vaccination to students. We recommend that HPV school-based vaccination programmes have access to our education package (updated as appropriate), or similar, so that educators can teach all students about HPV and HPV vaccination before they are invited to be vaccinated at school. This approach will promote informed young people who are better positioned to understand HPV and HPV vaccination, have positive attitudes towards vaccination and enhanced confidence on vaccination day (Figure 1).</p> <hd id="AN0122658711-25">Strengths and limitations</hd> <p>This comprehensive study, involving a random selection of 40 schools, allocated to control or intervention groups, employed a study design that reduced chance of systematic bias. It was conducted across two Australian states, and was broadly representative of the Australian population in our target group. Employing both quantitative and qualitative methods enabled us to gain greater insight about why and how the education intervention worked. Limitations included the fact that not all the HPV and HPV education was taught before HPV dose 1 was administered to students, which would have potentially reduced the knowledge gain in the intervention group pre-dose 1, but it may have assisted with persistence of knowledge, which was demonstrated. Since revision of unit content with students in an important part of any quality teaching and learning, it would have been ideal for teachers and/or school nurses to have provided revision, but this was not possible given time restrictions and an already full curriculum. Revision of this unit may have resulted in evidence of longer-term learning of HPV and HPV vaccination by students. While many of the 12 case study schools that participated in the qualitative study had higher than average ICSEA rankings, we expect that lower ranking ICSEA schools can also benefit from our education intervention for young people given the potential for reduced agency to access high quality, research based resources to educate students about HPV and HPV vaccination. School-based vaccination is a challenge for schools because it adds additional burden to educators. While not all schools could implement all resources, the intention of the education intervention was for schools to choose the most appropriate resources for their student cohort. Finally, the intervention was also designed to promote higher vaccination rates, primarily through the logistical components. Unfortunately this was not achieved, as the logistical intervention was not implemented as intended. At least one vaccine dose was given to 3277 (86.1%) students in intervention schools versus 2697 (85.4%) in control schools, difference 0.4% (95% CI: −2.6, 3.3). The complete findings from this part of the study, including vaccine course completion and detailed implementation and process evaluation have been presented[<reflink idref="bib27" id="ref95">27</reflink>] and will be published in a separate paper.</p> <hd id="AN0122658711-26">Conclusion</hd> <p>Study results showed that students in intervention schools demonstrated greater knowledge and understanding of HPV and HPV vaccination. Overall, greater knowledge and understanding of HPV and HPV vaccination appeared to promote positive attitudes towards vaccination and supported confidence with vaccination. The concepts of expectations, observational learning, behavioural capacity, and self-efficacy informed by the three guiding behavioural theories and as measured in our validated questionnaire, appeared to promote the outcomes observed in this study. HPV and HPV vaccination education for young people is useful to promote knowledge, understanding and healthy citizenship. Educators (teachers and school nurses), combined with their own knowledge and experience, found that an educator user guide, supplement and resources based on current research, made teaching students of vaccination age, about HPV and HPV vaccination in the school-setting feasible and achievable. 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.</p> <hd id="AN0122658711-27">Disclosure statement</hd> <p>No potential conflict of interest was reported by the authors.</p> <hd id="AN0122658711-28">Funding</hd> <p>This work was supported by the Australian National Health and Medical Research Council [grant application number 1026765]; Helen Marshall was supported by a NHMRC CDF 2 Fellowship [APP1084951]. GSK Australia [4806] provided an investigator initiated educational grant for the development of HPV educational materials, which were used in this study. Trial registration: Australian and New Zealand Clinical Trials Registry [ACTRN12614000404628], 14.04.2014; and Seqirus (BioCSL).</p> <hd id="AN0122658711-29">Acknowledgements</hd> <p>We would like to acknowledge the contributions to this study by members of the HPV.edu Study Group, including: Annette Braunack-Mayer: School of Population Health, University of Adelaide, Adelaide, SA, Australia; Julia Brotherton: National HPV Vaccination Program Register, VCS, and School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia; Suzanne M. Garland: Women's Centre for Infectious Diseases, The Royal Women's Hospital, Melbourne, VIC, Australia; Melissa Kang: Faculty of Health, Australian Centre for Public and Population Health Research, University of Technology Sydney; John Kaldor: The Kirby Institute for Infection and Immunity in Society, Faculty of Medicine, UNSW Sydney, NSW, Australia; Julie Leask; School of Public Health, University of Sydney, Sydney, NSW, Australia; Kirsten McCaffrey; David G. Regan: The Kirby Institute for Infection and Immunity in Society, Faculty of Medicine, UNSW Sydney, NSW, Australia; Peter Richmond: Vaccine Trials Group, Telethon Kids Institute, Perth, WA, Australia, and School of Paediatrics and Child Health, University of Western Australia, Perth, WA, Australia; Patti Whyte, Deakin University, SRC Population Health, Deakin Health Economics, Melbourne, VIC, Australia. We thank our study Advisory Boards in Western Australia and South Australia for their cooperation and their invaluable advice and feedback, and we also acknowledge the support of WA Health and SA Health. We wish to acknowledge the invaluable input of the research participants: the students, teachers, school nurses, parents/guardians and immunisation team members that allowed the research to be undertaken across schools in Western Australia and South Australia. We would like to acknowledge GSK for an investigator initiated educational grant (to fund educational materials); the BUPA Foundation (funded the decisional support tool); and Seqirus (BioCSL) for providing an investigator initiated research grant to assist in collection of data from boy. We also wish to acknowledge Gemma Abraham and Harrison Lindsay Odgers for their contribution to coding the qualitative data in NVivo. Gemma's contribution was enabled by the Sydney Medical School Summer Scholars Program, University of Sydney, Australia, and Harrison kindly donated his time to the HPV.edu study while completing his MPH.</p> <ref id="AN0122658711-30"> <title> Notes </title> <blist> <bibl id="bib1" idref="ref1" type="bt">1</bibl> <bibtext> Prevalence increases in women with cervical pathology in proportion to the severity of the lesion reaching around 90% in women with grade 3 cervical intraepithelial neoplasia and invasive cancer (Forman et al. [20]).</bibtext> </blist> <blist> <bibl id="bib2" idref="ref2" type="bt">2</bibl> <bibtext> Estimates for 2012–2016 (based on 2002–2011 incidence data) are presented.</bibtext> </blist> <blist> <bibl id="bib3" idref="ref3" type="bt">3</bibl> <bibtext> There are about 40 HPV geno-types that infect the mucosal areas of the body, such as the cells lining the anus, genital or oral tract, of which 13–18 types have been identified as high risk, due to their association with malignancy. The HPV genotype most commonly responsible for HPV-related malignancy is 16, followed by 18, 45, 33 and 31. The proportion of malignancies due to each type varies slightly by geographical area, but these five types are responsible for 70–90% of all HPV related cancers, depending on geographical area and cancer type (please see Trottier and Burchell [42]).</bibtext> </blist> <blist> <bibl id="bib4" idref="ref5" type="bt">4</bibl> <bibtext> Modelling suggests that HPV vaccination coverage rates need to be at target levels of 90% to reduce HPV disease burden.</bibtext> </blist> <blist> <bibl id="bib5" idref="ref60" type="bt">5</bibl> <bibtext> Regression models with Generalised Estimating Equations (GEE) were used to account for clustering within schools.</bibtext> </blist> <blist> <bibl id="bib6" idref="ref26" type="bt">6</bibl> <bibtext> The guide for educators is available as an attachment to download as part of our study protocol. See Skinner et al. [37].</bibtext> </blist> <blist> <bibl id="bib7" idref="ref64" type="bt">7</bibl> <bibtext> The website includes information about HPV and HPV vaccination and is intended to reinforce the information taught in class. Adolescents can re-watch the film clips, sign up to receive reminders about vaccination, and share their stories about being vaccinated.</bibtext> </blist> <blist> <bibl id="bib8" idref="ref28" type="bt">8</bibl> <bibtext> The magazine includes a range of practical information about HPV and HPV vaccination, and the school vaccination day, in an appealing format. The magazine is designed to be taken home by students to read in their own time.</bibtext> </blist> <blist> <bibl id="bib9" idref="ref51" type="bt">9</bibl> <bibtext> iPads were available for student use on vaccination day to assist with relaxation and distraction and contained only the study app, which incorporated information from the website, the film chapters, the magazine, and relaxation exercises and distraction activities such as a painting tool.</bibtext> </blist> <blist> <bibtext> 'HPV question panel,' 'Crossword puzzle,' 'Matching game,' 'Educate the public' and 'HPV Bingo'.</bibtext> </blist> <blist> <bibtext> 'Talk with your parent' and 'the decision-making process'.</bibtext> </blist> <blist> <bibtext> 'Meditation exercise'.</bibtext> </blist> <blist> <bibtext> 'What is HPV,' 'What is HPV vaccination,' ' Boys and HPV' and 'Vaccination in the Future'.</bibtext> </blist> <blist> <bibtext> 'HPV decision-making'.</bibtext> </blist> <blist> <bibtext> 'Vaccination on the day'.</bibtext> </blist> <blist> <bibtext> Utilisation of the website and education resources are included in the section below: Implementation of the education intervention.</bibtext> </blist> <blist> <bibtext> Specifically, we targeted area E in the broad learning sequence for years 7–8: (E) Students investigate health issues relevant to young people to understand reasons for the choices people make about their health and wellbeing. They examine personal, environmental and social factors that can influence an individual's choices and explore and evaluate options, consequences and healthier and safer alternatives. (ACARA [1] (August), 18)</bibtext> </blist> <blist> <bibtext> Each educator (teacher and/or school nurse) was invited to complete a log documenting lesson type, student year group, number of students in attendance at the HPV.edu lesson, sex of students, lesson time spent educating student about HPV and HPV vaccination, educational resources used, No. of students that received the magazine, number of students that undertook the student questionnaire, kinds of questions asked by students about HPV and HPV vaccination, educator confidence with responding to student questions, educator comments and suggestions regarding the education resources.</bibtext> </blist> <blist> <bibtext> The ICSEA ranking was determined by consulting the My School website: < https://www.myschool.edu.au> viewed 10 September 2016.</bibtext> </blist> <blist> <bibtext> The qualitative findings are supported by the findings in the quantitative survey. Forty-two per cent of students in the control group that participated in the HAVIQ student survey said they did not know whether they had completed the HPV vaccine course compared to 32% of students in the intervention group. These percentages exclude students that did not respond to this question.</bibtext> </blist> <blist> <bibtext> When a high percentage of the population is vaccinated, it is difficult for infectious diseases that are contagious to spread, because there are not many people who can be infected. Herd immunity only works if most people in the population are vaccinated. See Vaccine Knowledge Project, University of Oxford: <ulink href="http://vk.ovg.ox.ac.uk/herd-immunity,">http://vk.ovg.ox.ac.uk/herd-immunity,</ulink> accessed 1 July 2016.</bibtext> </blist> <blist> <bibtext> Expectations refer to an individual's belief about the probable results from their actions.</bibtext> </blist> <blist> <bibtext> Observational learning refers to individuals learning from one another through watching each other's behaviour, attitudes and outcomes of those behaviours.</bibtext> </blist> <blist> <bibtext> Behavioural capacity refers to the knowledge and skills that are necessary to effect or change behaviour.</bibtext> </blist> <blist> <bibtext> Self-efficacy refers to an individual's confidence of their ability to overcome perceived barriers.</bibtext> </blist> <blist> <bibtext> Please note that these are the results for the qualitative findings. We did not ask a specific question in the HAVIQ student survey about other HPV related cancers, and therefore cannot provide the percentage of students who lacked knowledge about other HPV-related cancers.</bibtext> </blist> <blist> <bibtext> Please see: LB1.1 Randomised controlled trial of a complex intervention to improve school-based hpv vaccination for adolescents: the hpv. edu study <ulink href="http://sti.bmj.com/content/91/Suppl%5f2/A77.1.abstract?sid=953e0699-b984-42e3-a59c-5b8620425003">http://sti.bmj.com/content/91/Suppl%5f2/A77.1.abstract?sid=953e0699-b984-42e3-a59c-5b8620425003</ulink></bibtext> </blist> </ref> <ref id="AN0122658711-31"> <title> References </title> <blist> <bibtext> ACARA. 2012. The Shape of the Australian Curriculum: Health and Physical Education. Sydney: Australian Curriculum, Assessment and Reporting Authority.</bibtext> </blist> <blist> <bibtext> Agius, P. A. 2010. 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  Data: <searchLink fieldCode="DE" term="%22Sexually+Transmitted+Diseases%22">Sexually Transmitted Diseases</searchLink><br /><searchLink fieldCode="DE" term="%22Immunization+Programs%22">Immunization Programs</searchLink><br /><searchLink fieldCode="DE" term="%22Foreign+Countries%22">Foreign Countries</searchLink><br /><searchLink fieldCode="DE" term="%22Randomized+Controlled+Trials%22">Randomized Controlled Trials</searchLink><br /><searchLink fieldCode="DE" term="%22Intervention%22">Intervention</searchLink><br /><searchLink fieldCode="DE" term="%22Sex+Education%22">Sex Education</searchLink><br /><searchLink fieldCode="DE" term="%22Experimental+Groups%22">Experimental Groups</searchLink><br /><searchLink fieldCode="DE" term="%22Control+Groups%22">Control Groups</searchLink><br /><searchLink fieldCode="DE" term="%22Mixed+Methods+Research%22">Mixed Methods Research</searchLink><br /><searchLink fieldCode="DE" term="%22Semi+Structured+Interviews%22">Semi Structured Interviews</searchLink><br /><searchLink fieldCode="DE" term="%22Focus+Groups%22">Focus Groups</searchLink><br /><searchLink fieldCode="DE" term="%22Early+Adolescents%22">Early Adolescents</searchLink><br /><searchLink fieldCode="DE" term="%22High+School+Students%22">High School Students</searchLink>
– Name: Subject
  Label: Geographic Terms
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Australia%22">Australia</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1080/14681811.2017.1300770
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 1468-1811
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: The National Human Papillomavirus (HPV) Vaccination Program in Australia commenced in 2007 for girls and in 2013 for boys, using the quadrivalent HPV [4vHPV] vaccine. In Australia, students are primarily vaccinated en masse, on school grounds, after parental/ guardian consent is obtained. Students most often receive little, or no, education at school about HPV or HPV vaccination prior to immunisation. There is also some uncertainty about where young people can and should obtain reliable information about the vaccine, outside of school. We conducted a cluster randomised controlled trial of a complex intervention in schools. This study aimed to improve: (1) student knowledge about HPV vaccination; (2) psycho-social outcomes and (3) vaccination uptake. In this paper, we briefly outline our educational intervention and discuss its implementation by educators including facilitators and barriers. We also discuss the study findings pertaining to student knowledge about HPV and HPV vaccination and their attitudes to vaccination across control and intervention schools. Study results showed students in intervention schools demonstrate greater knowledge and understanding of HPV and HPV vaccination. Greater knowledge and understanding of HPV and HPV vaccination appeared to promote positive attitudes towards vaccination and supported confidence with vaccination.
– Name: AbstractInfo
  Label: Abstractor
  Group: Ab
  Data: As Provided
– Name: Ref
  Label: Number of References
  Group: RefInfo
  Data: 44
– Name: DateEntry
  Label: Entry Date
  Group: Date
  Data: 2017
– Name: AN
  Label: Accession Number
  Group: ID
  Data: EJ1138659
PLink https://search.ebscohost.com/login.aspx?direct=true&site=eds-live&db=eric&AN=EJ1138659
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      – Type: doi
        Value: 10.1080/14681811.2017.1300770
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      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 20
        StartPage: 256
    Subjects:
      – SubjectFull: Sexually Transmitted Diseases
        Type: general
      – SubjectFull: Immunization Programs
        Type: general
      – SubjectFull: Foreign Countries
        Type: general
      – SubjectFull: Randomized Controlled Trials
        Type: general
      – SubjectFull: Intervention
        Type: general
      – SubjectFull: Sex Education
        Type: general
      – SubjectFull: Experimental Groups
        Type: general
      – SubjectFull: Control Groups
        Type: general
      – SubjectFull: Mixed Methods Research
        Type: general
      – SubjectFull: Semi Structured Interviews
        Type: general
      – SubjectFull: Focus Groups
        Type: general
      – SubjectFull: Early Adolescents
        Type: general
      – SubjectFull: High School Students
        Type: general
      – SubjectFull: Australia
        Type: general
    Titles:
      – TitleFull: 'Is It Like One of Those Infectious Kind of Things?' The Importance of Educating Young People about HPV and HPV Vaccination at School
        Type: main
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            NameFull: Zimet, Gregory
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              Y: 2017
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            – TitleFull: Sex Education: Sexuality, Society and Learning
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