Linda Bennett

Exploring Indonesian Primary Schoolgirls’ Experiences of School-based HPV Vaccination, Knowledge of HPV Risks and Prevention, and Preferences for Cervical Cancer Education

In 2016, Indonesia introduced its Human Papillomavirus (HPV) vaccination demonstration program for girls in grades 5 and 6 of primary school, to reduce cervical cancer (CC) burden in selected provinces and test the viability of nationwide vaccination. This study explored schoolgirls' experience of school-based HPV vaccination, their knowledge of HPV and HPV vaccination, and their preferences for cervical cancer (CC) education. An online survey was conducted with schoolgirls who experienced HPV vaccination between 2019 and 2021 through the demonstration program. Using purposive sampling, respondents were recruited through partnerships with primary public health centres and primary schools in Jakarta and Yogyakarta. Data analysis was conducted using Chi-square test, Independent-samples t-test, and one-way ANOVA. One hundred and forty primary schoolgirls with a mean age of 12.2 years (SD = 0.70) completed the survey. Schools and mothers were identified as key actors in socialising children about important health information and as girls' preferred sources of information. The average summed score for girls' knowledge of HPV, the HPV vaccine, and CC after being vaccinated was 5.07 out of 10 (SD 0.23). Significant differences in the mean knowledge scores among participants with different preferences regarding CC education in school were observed. While schoolgirls' experiences of HPV vaccination were largely positive, their knowledge of critical health information regarding HPV vaccination and CC prevention needs improving. Thus, it is necessary to provide parents, and school-based educators with culturally appropriate strategies and comprehensive evidence-based information about HPV vaccination and CC prevention more effectively to children.

Facilitators and barriers for the delivery and uptake of cervical cancer screening in Indonesia: a scoping review

Cervical cancer (CC) is the second most common female cancer. In Indonesia, national CC screening coverage is low at 12%, highlighting the need to investigate facilitators and barriers to screening. This review synthesises research on facilitators and barriers to the delivery and uptake of CC screening; analyses them in terms of supply- and demand-side factors and their interconnectedness; and proposes recommendations for further research. Medline Ovid, CINAHL, Global Health, Neliti, SINTA and Google Scholar were searched, applying a search string with keywords relevant to screening, CC and Indonesia. In total 34 records were included, all were publications on CC screening in Indonesia (2000-2020) in English or Indonesian. Records were analysed to identify findings relevant to the categories of barriers and facilitators, supply-and demand-side factors. Demand-side facilitators identified included:  husband, family or social/peer support (14 studies); information availability, knowledge and awareness (12 studies); positive attitudes and strong perception of screening benefit and the seriousness of CC (12 studies); higher education and socioeconomic status (11 studies); having health insurance; and short distance to screening services (4 studies). Evidence on supply-side was limited. Supply-side facilitators included counselling and support (6 studies), and ease of access (6 studies). Demand-side barriers identified focused on: lack of knowledge/awareness and lack of confidence in screening (14 studies); fear, fatalism and shame (10 studies); time and transportation constraints (8 studies); and lack of husband approval and support (6 studies). Supply-side barriers included: lack of skilled screening providers (3 studies); lack of advocacy and health promotion (3 studies); resource constraints (3 studies); and lack of supervision and support for health care providers (3 studies). Facilitators and barriers were mirrored in the supply- and demand-side findings. The geographical scope and population diversity of existing research is limited and further supply-side research is urgently needed.

Unpacking cervical cancer stigma in healthcare: lessons learnt from Indonesian patients and health professionals

Indonesia has the highest cervical cancer incidence and mortality rates in Southeast Asia, with 36,000 new diagnoses and 21,000 deaths occurring in 2020. This situation stems from delayed introduction of free HPV vaccination, poor uptake of cervical screening, and widespread stigmatisation of cervical cancer. Ethnographic research conducted between 2019 and 2021 documented women's experiences of cervical cancer stigma in healthcare, stigmatising narratives and practices exhibited by health professionals, and non-stigmatising practices demonstrated by health professionals. Four dominant narratives were identified including stigma based on: perceived sexual immorality; marital status; low socio-economic status and/or education; and discourses of pollution associated with vaginal bleeding and female hygiene. Lessons learned provide culturally grounded insights for achieving stigma-free healthcare, such as avoiding: blaming women or their partners; linking cervical cancer with sexual impropriety; mentioning sex work or enquiring about women's or their partners' professions; negative references to female hygiene or vaginal bleeding; and reference to patients' class, education level, marital status or other personal attributes. The representation of HPV as a common infection occurring within marriage was shown to be an effective strategy for avoiding stigma, while institutional change was identified as necessary to remove barriers to reproductive health service access related to marital status.