Year

2022

Degree Name

Doctor of Philosophy

Department

School of Medicine

Abstract

Background: Understanding parents’ decisions or intentions regarding HPV vaccination for their daughters in Jakarta, Indonesia is important, and provides insight into factors that have contributed to uptake to inform future program development.

Method: This research is a concurrent mixed method study. In the quantitative component, 680 parents or guardians of year 6 female students from 33 primary schools who were offered free HPV vaccination were invited to complete a questionnaire. Multivariate multilevel logistic regression analysis was done in two groups: the ‘Decided’ Group (those parents who allowed or refused for their daughter to receive the HPV vaccination), and the ‘Undecided’ Group (those parents who did not recall being approached about the HPV vaccination or forgot their response). In the qualitative component, 24 parents in Jakarta, Indonesia, were interviewed to explore what factors shaped their decisions regarding the free school-based HPV vaccine for their daughters. Results fell under three major themes: attitudes; subjective norms; and perceived behavioural control. Results from both components were then synthesised and analysed.

Results: Four hundred and eighty-four (71%) completed the survey in the quantitative component. Results showed that 295 (83.6%) parents in the ‘Decided’ group 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. Attitudes, subjective norms and perceived behavioural control were shown to be significant predictors in the ‘Decided’ group, while no independent variable was seen as a significant predictor in the ‘Undecided’ group. Findings from the qualitative component showed that whilst parents had limited knowledge about cervical cancer and the HPV vaccine, many had positive attitudes and believed that the vaccine offered protection from cervical cancer. Having the vaccine provided free of charge seemed to increase parents’ sense of control of being able to provide protection for their daughters from cervical cancer, and peer approval was also important to guide their decision-making. The mixed methods analysis showed that the interview findings generally supported the survey findings. Positive attitudes towards vaccinations in general were translated into positive attitudes toward HPV vaccination. The analysis also explained how offering the HPV vaccination for free changed parents’ low perceived behavioural control into a high level of actual control, and how parents’ trust in health care providers, government and their peers also guided their decision-making.

Conclusion: Rolling out the HPV vaccination program to all eligible Indonesian girls is an important step in decreasing cervical cancer incidence and mortality in Indonesia. Findings from this study demonstrate that the free school-based HPV vaccination program for girls in Jakarta is acceptable in terms of cost and convenience to parents and results in a high uptake of HPV vaccination, despite some parents having limited knowledge regarding the benefits and the risks of HPV vaccination. The way parents received health information (through pamphlets, media, online sources or direct counselling), may also impact their perceptions. Targeted health information campaigns, supported by health care providers, are needed to address lack of knowledge and misinformation. A direct counselling approach might be beneficial in areas with lower literacy or in those areas where the use of local languages is still prominent, and people cannot read Indonesian text. Other delivery strategies are required to capture eligible-aged girls who no longer attend school. Future programs also need to explore other strategies such as multiple SMS and email reminders as opposed to just paper-based strategies to remind parents of the vaccination offer. Further research is needed to explore the views of policymakers, other stakeholders and parents who have geographic, socioeconomic, language or cultural barriers.

Comments

Thesis by publication

Parts of this thesis are under embargo until 21st January 2025

FoR codes (2020)

4206 Public health, 420603 Health promotion, 420605 Preventative health care, 420606 Social determinants of health

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Unless otherwise indicated, the views expressed in this thesis are those of the author and do not necessarily represent the views of the University of Wollongong.