A community-based program to reduce acute rheumatic fever and rheumatic heart disease in northern Australia.

BACKGROUND: In Australia's north, Aboriginal peoples live with world-high rates of rheumatic heart disease (RHD) and its precursor, acute rheumatic fever (ARF); driven by social and environmental determinants of health. We undertook a program of work to strengthen RHD primordial and primary prevention using a model addressing six domains: housing and environmental support, community awareness and empowerment, health literacy, health and education service integration, health navigation and health provider education. Our aim is to determine how the model was experienced by study participants. METHODS: This is a two-year, outreach-to-household, pragmatic intervention implemented by Aboriginal Community Workers in three remote communities. The qualitative component was shaped by Participatory Action Research. Yarning sessions and semi-structured interviews were conducted with 14 individuals affected by, or working with, ARF/RHD. 31 project field reports were collated. We conducted a hybrid inductive-deductive thematic analysis guided by critical theory. RESULTS: Aboriginal Community Workers were best placed to support two of the six domains: housing and environmental health support and health navigation. This was due to trusting relationships between ACWs and families and the authority attributed to ACWs through the project. ACWs improved health literacy and supported awareness and empowerment; but this was limited by disease complexities. Consequently, ACWs requested more training to address knowledge gaps and improve knowledge transfer to families. ACWs did not have skills to provide health professionals with education or ensure health and education services participated in ARF/RHD. Where knowledge gain among participant family members was apparent, motivation or structural capability to implement behaviour change was lacking in some domains, even though the model was intended to support structural changes through care navigation and housing fixes. CONCLUSIONS: This is the first multi-site effort in northern Australia to strengthen primordial and primary prevention of RHD. Community-led programs are central to the overarching strategy to eliminate RHD. Future implementation should support culturally safe relationships which build the social capital required to address social determinants of health and enable holistic ways to support sustainable individual and community-level actions. Government and services must collaborate with communities to address systemic, structural issues limiting the capacity of Aboriginal peoples to eliminate RHD.

Sociocultural and individual determinants for motivation of sexual and reproductive health workers in Papua New Guinea and their implications for male circumcision as an HIV prevention strategy.

BACKGROUND: The motivation of health workers (HWs) to deliver services in developing countries has been described as a critical factor in the success of health systems in implementing programmes. How the sociocultural context of Papua New Guinea (PNG) affects the values, motivation and actions of HWs involved in sexual and reproductive health services is important for policy development and programme planning. With interest in male circumcision (MC) as an HIV prevention option in PNG, this study explored the perceptions and motivations of HWs involved in sexual and reproductive health services in PNG, examining their implications for the possible future roll out of a national MC programme. METHODS: A multi-method qualitative study was conducted with HWs across a range of health care professions working in sexual health facilities. A total of 29 in-depth interviews and one focus group discussion were completed. Qualitative thematic analysis of the transcripts and field notes was undertaken using a social constructivist approach and complemented by documentary organizational, programme and policy analysis. RESULTS AND DISCUSSIONS: Introduction of new health programmes, such as a MC programme for HIV prevention, are likely to impact upon one or more of the many motivational determinants. Social-cultural and individual factors influencing HW motivation to be involved in sexual and reproductive health services in PNG included community expectation and concern, sense of accomplishment and religious conviction. Strong links to community responsibility outweighed organizational ties. Faced with an often dysfunctional work environment, HWs perceived themselves as responsible to compensate for the failed health system. The impact of community influence and expectation needs to be considered when introducing a MC programme, particularly to communities in PNG where penile foreskin cutting is a common and accepted practice. CONCLUSIONS: The potential contribution to the success of a MC programme that HWs may have means that taking into account the differing needs of communities as well as the motivational influences on HWs that exist within the sociocultural environment is important. These findings will assist not only in programme planning for MC, but also in the expansion of other existing sexual and reproductive health services.

Sexual risk behaviour, marriage and ART: a study of HIV-positive people in Papua New Guinea.

BACKGROUND: The prevention of intimate partner transmission of HIV remains an important component of comprehensive HIV prevention strategies. In this paper we examine the sexual practices of people living with HIV on antiretroviral therapy (ART) in Papua New Guinea (PNG). METHOD: In 2008, a total of 374 HIV-positive people over the age of 16 and on ART for more than two weeks were recruited using a non-probability, convenience sampling methodology. This accounted for around 18% of adults on ART at the time. A further 36 people participated in semi-structured interviews. All interviews were thematically analysed using NVivo qualitative data analysis software. RESULTS: Less than forty per cent (38%) of participants reported having had sexual intercourse in the six months prior to the survey. Marital status was by far the most important factor in determining sexual activity, but consistent condom use during vaginal intercourse with a regular partner was low. Only 46% reported consistent condom use during vaginal intercourse with a regular partner in the last six months, despite 77% of all participants reporting that consistent condom use can prevent HIV transmission. Consistent condom use was lowest amongst married couples and those in seroconcordant relationships. The vast majority (91.8%) of all participants with a regular heterosexual partner had disclosed their status to their partner. Qualitative data reinforced low rates of sexual activity and provided important insights into sexual abstinence and condom use. CONCLUSIONS: Considering the importance of intimate partner transmission of HIV, these results on the sexual practices of people with HIV on ART in PNG suggest that one-dimensional HIV prevention messages focussing solely on condom use fail to account for the current practices and needs of HIV-positive people, especially those who are married and know their partners' HIV status.

Listening to diverse community voices: the tensions of responding to community expectations in developing a male circumcision program for HIV prevention in Papua New Guinea.

BACKGROUND: The success of health programs is influenced not only by their acceptability but also their ability to meet and respond to community expectations of service delivery. The World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) have recommended medical male circumcision (MC) as an essential component of comprehensive HIV prevention programs in high burden settings. This study investigated community-level perceptions of MC for HIV prevention in Papua New Guinea (PNG), a setting where diverse traditional and contemporary forms of penile foreskin cutting practices have been described. METHODS: A multi-method qualitative study was undertaken in four provinces in two stages from 2009 to 2011. A total of 82 in-depth interviews, and 45 focus group discussions were completed during Stage 1. Stage 2 incorporated eight participatory workshops that were an integral part of the research dissemination process to communities. The workshops also provided opportunity to review key themes and consolidate earlier findings as part of the research process. Qualitative data analysis used a grounded theory approach and was facilitated using qualitative data management software. RESULTS: A number of diverse considerations for the delivery of MC for HIV prevention in PNG were described, with conflicting views both between and within communities. Key issues included: location of the service, service provider, age eligibility, type of cut, community awareness and potential shame amongst youth. Key to developing appropriate health service delivery models was an appreciation of the differences in expectations and traditions of unique cultural groups in PNG. Establishing strong community coalitions, raising awareness and building trust were seen as integral to success. CONCLUSIONS: Difficulties exist in the implementation of new programs in a pluralistic society such as PNG, particularly if tensions arise between biomedical knowledge and medico-legal requirements, compared to existing socio-cultural interests. Community participatory approaches offer important opportunities to explore and design culturally safe, specific and accessible programs.

Why women object to male circumcision to prevent HIV in a moderate-prevalence setting.

Adult male circumcision has been shown to reduce the transmission of HIV. Women's acceptability of male circumcision is important in Papua New Guinea's preparedness to introduce male circumcision, and in ethical considerations of its use as a biomedical technology for HIV prevention. We conducted 21 focus group discussions and 18 in-depth interviews with women in all four regions of Papua New Guinea. The majority of women objected to the introduction of male circumcision for three main reasons: circumcision would result in sexual risk compensation; circumcision goes against Christian faith; and circumcision is a new practice that is culturally inappropriate. A minority of women accepted male circumcision for the prevention of HIV and other sexually transmitted infections, and for the benefit of penile hygiene and health. Women's objections to circumcision as a biomedical method of preventing HIV reemphasize the importance of sociocultural and behavioral interventions in Papua New Guinea.

Mixed methods study of student participation and self-efficacy in remote asynchronous undergraduate physics laboratories: contributors, lurkers, and outsiders.

Background: While laboratory practices have traditionally been conducted in-person, online asynchronous laboratory learning has been growing in popularity due to increased enrollments and the recent pandemic, creating opportunities for accessibility. In remote asynchronous learning environments, students have more autonomy to choose how they participate with other students in their laboratory classes. Communities of practice and self-efficacy may provide insights into why students are making their participation choices and how they are interacting with peers in asynchronous physics laboratory courses. Results: In this mixed methods, explanatory sequential study, students in an introductory physics remote asynchronous laboratory (N = 272) were surveyed about their social learning perceptions and their physics laboratory self-efficacy. Three groups of students were identified based upon their self-reported participation level of communication with peers in asynchronous courses: (1) contributors, who communicated with peers via instant messaging software and posted comments; (2) lurkers, who read discussions on instant messaging software without posting comments; and (3) outsiders, who neither read nor posted comments to peer discussions. Analysis of variance with post hoc Tukey tests showed significant differences in social learning perceptions among contributors, lurkers, and outsiders, with a large effect size, and differences between contributing and lurking students' self-efficacy, with a small effect size. Qualitative findings from open-ended survey responses indicated contributors felt the structure of the learning environment, or their feeling of connectedness with other students, facilitated their desire to contribute. Many lurkers felt they could get what they needed through vicarious learning, and many expressed their lack of confidence to post relevant, accurate comments. Outsiders felt they did not have to, did not want to, or could not connect with other students. Conclusions: While the classroom laboratory traditionally requires all students to participate in the learning process through active socialization with other students, students in a remote asynchronous laboratory may still gain the benefits of participation through lurking. Instructors may consider lurking in an online or remote science laboratory as a legitimate form of participation and engagement.

A typology of penile cutting in Papua New Guinea: results of a modified Delphi study among sexual health specialists.

Male circumcision (MC) significantly reduces the risk of HIV acquisition in men. The geographical, linguistic and cultural diversity of Papua New Guinea (PNG) makes issues of acceptability and implementation complex, and culturally appropriate HIV and Sexually Transmissible Infection (STI) prevention strategies are crucial in this setting. A modified Delphi approach was conducted with sexual health specialists to document and classify variants of penile cutting as part of a programme of research being carried out to investigate the acceptability and potential epidemiological impact of MC for HIV prevention in PNG, and options for future roll-out. Three broad categories were identified: circumcision, longitudinal incisions (including dorsal slit procedures) and incisions that did not alter the profile of penis or foreskin. The typology provides a universal language for health practitioners and policy makers that will inform future sexual health deliberations. The popularity of dorsal slit procedures in PNG has significant implications due to its procedural simplicity and limited resource requirements, making it an attractive provider option compared to medical circumcision. Further research is urgently required to examine the effectiveness of dorsal slit procedures for HIV prevention in PNG, the prevalence of various forms of penile cutting and the extent to which health staff are currently engaged in dorsal slit procedures.

"Now we are in a different time; various bad diseases have come." Understanding men's acceptability of male circumcision for HIV prevention in a moderate prevalence setting.

BACKGROUND: Adult male surgical circumcision (MC) has been shown to reduce HIV acquisition in men and is recommended by the WHO for inclusion in comprehensive national HIV prevention programs in high prevalence settings. Only limited research to date has been conducted in countries experiencing moderate burden epidemics, where the acceptability, operational feasibility and potential epidemiological impact of MC remain unclear. METHODS: A multi-method qualitative research study was conducted at four sites in Papua New Guinea (PNG), with 24 focus group discussions and 65 in-depth interviews carried out among 276 men. RESULTS: The majority of men were in favour of MC being introduced for HIV prevention in PNG and considered improved genital hygiene, enhanced sexual pleasure and culturally appropriateness key factors in the acceptability of a future intervention. A minority of men were against the introduction of MC, primarily due to concerns regarding sexual risk compensation and that the intervention went against prevailing cultural and religious beliefs. CONCLUSION: This is one of the first community-based MC acceptability studies conducted in a moderate prevalence setting outside of Africa. Research findings from this study suggest that a future MC program for HIV prevention would be widely accepted by men in PNG.

Vasectomy as a proxy: extrapolating health system lessons to male circumcision as an HIV prevention strategy in Papua New Guinea.

BACKGROUND: Male circumcision (MC) has been shown to reduce the risk of HIV acquisition among heterosexual men, with WHO recommending MC as an essential component of comprehensive HIV prevention programs in high prevalence settings since 2007. While Papua New Guinea (PNG) has a current prevalence of only 1%, the high rates of sexually transmissible diseases and the extensive, but unregulated, practice of penile cutting in PNG have led the National Department of Health (NDoH) to consider introducing a MC program. Given public interest in circumcision even without active promotion by the NDoH, examining the potential health systems implications for MC without raising unrealistic expectations presents a number of methodological issues. In this study we examined health systems lessons learned from a national no-scalpel vasectomy (NSV) program, and their implications for a future MC program in PNG. METHODS: Fourteen in-depth interviews were conducted with frontline health workers and key government officials involved in NSV programs in PNG over a 3-week period in February and March 2011. Documentary, organizational and policy analysis of HIV and vasectomy services was conducted and triangulated with the interviews. All interviews were digitally recorded and later transcribed. Application of the WHO six building blocks of a health system was applied and further thematic analysis was conducted on the data with assistance from the analysis software MAXQDA. RESULTS: Obstacles in funding pathways, inconsistent support by government departments, difficulties with staff retention and erratic delivery of training programs have resulted in mixed success of the national NSV program. CONCLUSIONS: In an already vulnerable health system significant investment in training, resources and negotiation of clinical space will be required for an effective MC program. Focused leadership and open communication between provincial and national government, NGOs and community is necessary to assist in service sustainability. Ensuring clear policy and guidance across the entire sexual and reproductive health sector will provide opportunities to strengthen key areas of the health system.

More than just a cut: a qualitative study of penile practices and their relationship to masculinity, sexuality and contagion and their implications for HIV prevention in Papua New Guinea.

BACKGROUND: Male circumcision (MC) has been shown to reduce vaginal transmission of HIV to men. While community acceptability is important in a countries preparedness to introduce MC, it is equally important to map contemporary MC and other penile cutting practices, and the socio-cultural dimensions underpinning these practices. METHODS: A total of 482 men and women (n = 276 and n = 210, respectively) participated in 82 semi-structured and 45 focus group discussions from four different provinces of Papua New Guinea (PNG), each representing one of the four socially and geographically diverse regions of the country. RESULTS: Of the men interviewed 131 self-reported that they had undergone a penile alteration with some reporting multiple types. Practices were diverse and could be grouped into five broad categories: traditional (customary) penile cutting; contemporary penile cutting; medical circumcision; penile inserts; and penile bloodletting practices in which sharp objects are used to incise the glans and or inserted and withdrawn from the male urethra or in order to induce bleeding. Socio-cultural traditions, enhanced sexual pleasure and improved genital hygiene were key motivators for all forms of penile practices. CONCLUSIONS: The findings from this study highlight the complex and diverse nature of penile practices in PNG and their association with notions of masculinity, sexuality and contagion. Contemporary penile practices are critical to a community's acceptance of MC and of a country's ability to successfully implement MC in the context of a rich and dynamic culture of penile practices. If a MC program were to be successfully rolled out in PNG to prevent HIV it would need to work within and build upon these diverse cultural meanings and motivators for penile practices already commonly performed in PNG by men.

The implementation of a pilot playground markings project in four Australian primary schools.

ISSUE ADDRESSED: Increasing childhood overweight and obesity rates need strategies that promote and engage children in more physical activity and school is one setting for this. This pilot project aimed to determine if coloured playground markings are an effective strategy, in the Australian context, to increase students' physical activity during school break times in primary schools. METHODS: Four schools participated, two as intervention schools and two as control schools. A combination of data collection methods were used, including accelerometers on students, playground observations and a teacher survey. RESULTS: The accelerometer and observation data did not show an improvement in the physical activity levels of the intervention students compared to the control students. The teacher survey was positive in all aspects of the project implementation. Observations suggest that most students were active in large grass areas rather than around the playground markings. CONCLUSION: Based on our data, it is unclear whether playground markings are an effective intervention to increase physical activity in the school setting. The amount of playing space available appears to influence the use of the playground markings.

This is how we do it.

The purpose of this article is to explore students' experiences of variations in practice and how this impacts on their learning. This is particularly pertinent in terms of reconfiguration of services instigated by the Department of Health's (DH) Making it better agenda (DH 2007), meaning that many qualified staff are moving hospitals and also experiencing changes in practice. Students are thus being mentored by a range of mentors in a variety of settings, which can often mean that practice can be perceived as inconsistent and even idiosyncratic (Jones et al 2005). This writing is unique in that the midwifery lecturer facilitated the students' development of the work in a truly collaborative piece, developed through a writing and journal club. All details of the practice placements and the student comments have been anonymised.

Evaluation of a Community-Led Program for Primordial and Primary Prevention of Rheumatic Fever in Remote Northern Australia.

Environmental factors including household crowding and inadequate washing facilities underpin recurrent streptococcal infections in childhood that cause acute rheumatic fever (ARF) and subsequent rheumatic heart disease (RHD). No community-based 'primordial'-level interventions to reduce streptococcal infection and ARF rates have been reported from Australia previously. We conducted a study at three Australian Aboriginal communities aiming to reduce infections including skin sores and sore throats, usually caused by Group A Streptococci, and ARF. Data were collected for primary care diagnoses consistent with likely or potential streptococcal infection, relating to ARF or RHD or related to environmental living conditions. Rates of these diagnoses during a one-year Baseline Phase were compared with a three-year Activity Phase. Participants were children or adults receiving penicillin prophylaxis for ARF. Aboriginal community members were trained and employed to share knowledge about ARF prevention, support reporting and repairs of faulty health-hardware including showers and provide healthcare navigation for families focusing on skin sores, sore throat and ARF. We hypothesized that infection-related diagnoses would increase through greater recognition, then decrease. We enrolled 29 participants and their families. Overall infection-related diagnosis rates increased from Baseline (mean rate per-person-year 1.69 [95% CI 1.10-2.28]) to Year One (2.12 [95% CI 1.17-3.07]) then decreased (Year Three: 0.72 [95% CI 0.29-1.15]) but this was not statistically significant (p = 0.064). Annual numbers of first-known ARF decreased, but numbers were small: there were six cases of first-known ARF during Baseline, then five, 1, 0 over the next three years respectively. There was a relationship between household occupancy and numbers (p = 0.018), but not rates (p = 0.447) of infections. This first Australian ARF primordial prevention study provides a feasible model with encouraging findings.

Living serodiscordantly in Papua New Guinea: sexual practices of HIV-positive people on ART by serostatus of regular heterosexual partner.

This paper examines condom use in intimate relationships amongst Papua New Guineans on antiretroviral therapy (ART). These findings are from a mixed-method study in six provinces throughout Papua New Guinea (PNG). A total of 374 HIV-positive adult Papua New Guineans, over the age of 16 and on ART for more than two weeks were recruited using a non-probability, convenience sampling methodology. Participants were recruited through ART prescribing sites, People Living with HIV/AIDS (PLWHA) drop-in clinics and support groups. A small number (36) also participated in in-depth interviews. Of the sample 226 (60.4%) were women and 148 (39.6%) were men. The majority of the sample was aged below 40 years, with a median age of 30 years. Of the sample who were in a regular relationship 64.7% identified themselves as being in a relationship where both they and their partner were HIV-positive (seroconcordant). Smaller proportions (21.0%) reported being in a relationship with a HIV-negative partner (serodiscordant), or in a relationship where they were not aware of their partner's HIV status (14.3%). The majority of participants who reported having a regular partner also reported having disclosed their HIV serostatus to their partner (91.8%). A significantly greater proportion of participants who reported being in relationships where they did not know the status of their partner, also reported living in the Southern Region of PNG (52.9%), while the majority of those in seroconcordant relationships lived in the Highlands Region (71.2%). There did not appear to be any differences in sexual practice of using condoms between the three groups. Knowledge of serostatus is important for "positive prevention".

Formative evaluation of a community-based approach to reduce the incidence of Strep A infections and acute rheumatic fever.

OBJECTIVES: To explore the acceptability of a novel, outreached-based approach to improve primary and primordial prevention of Strep A skin sores, sore throats and acute rheumatic fever in remote Aboriginal communities. METHODS: A comprehensive prevention program delivered by trained Aboriginal Community Workers was evaluated using approximately fortnightly household surveys about health and housing and clinical records. RESULTS: Twenty-seven primary participants from three remote Aboriginal communities in the Northern Territory consented, providing 37.8 years of retrospective baseline data and 18.5 years of prospective data during the study period. Household members were considered to be secondary participants. Five Aboriginal Community Workers were trained and employed, delivering a range of supports to households affected by acute rheumatic fever including environmental health support and education. Clinical record audit and household self-report of Strep A infections were compared. No association between clinical- and self-report was identified. CONCLUSIONS: Ongoing participation suggests this outreach-based prevention program was acceptable and associated with improved reporting of household maintenance issues and awareness of prevention opportunities for Strep A infections. Implications for public health: Biomedical, clinic-based approaches to the management of Strep A infections in remote communities can be usefully augmented by outreach-based supports delivered by Aboriginal Community Workers responding to community needs.

Gendered talk about sex, sexual relationships and HIV among young people in Papua New Guinea.

This paper presents findings from a qualitative study carried out in three secondary schools in Eastern Highlands Province, Papua New Guinea (PNG). Seventy-three Year 12 students took part in eight gender-specific focus group discussions (three female and five male). Irrespective of gender, respondents predominately understood sex as being for the sole purpose of reproduction within marriage. When discussing sex and sexual relationships, young men used explicit language and referred specifically to sexual organs and activities. Young women did not. Less concerned for privacy, young men talked in public spaces and in groups with same-sex peers about sex and sexual expression, whereas young women discussed such matters one-on-one and in private. These gender differences provide useful entry points for developing appropriate sex and HIV education programmes involving young people in PNG.

Lost the feel for the game: meanings of onset and diagnosis of AIDS dementia for significant others.

The onset and diagnosis of AIDS dementia marks a new dimension to living with HIV, an aspect few imagine or are equipped for. As a result of the profound changes that AIDS dementia makes to the ways the person with HIV acts, the life of significant others is similarly altered. Drawing on the metaphor of "the game" from Bourdieu's work on habitus, I explore how the onset and subsequent diagnosis of AIDS dementia comes to signify for significant others a moment in which life is permanently altered, whereby they no longer have the feel for the game. With AIDS dementia, life ("the game") is altered. Significant others feel that AIDS dementia is not a normal or acceptable AIDS illness: fears are contested, secrets managed and disclosed, and relations strained. This change in play further marginalizes significant others, and increases their sense of alterity from others living with and affected by HIV alone, because dementia is not the socially acceptable way of being ill with HIV.

The body of Christ has AIDS: the Catholic Church responding faithfully to HIV and AIDS in Papua New Guinea.

Using the example of the Catholic Church in Papua New Guinea (PNG), I detail how, through praxis, it has brought to life a living theology of HIV and AIDS. In this way, the Catholic Church in PNG is responding faithfully to the epidemic. As a Christian country with a generalised HIV epidemic, where the body of an individual is reconstituted through the liturgical practices of baptism and Eucharist, theologically, in PNG the body of Christ has AIDS. In order to examine the ways in which the Catholic Church in PNG has responded faithfully to the Christian body with AIDS, I do so in relation to the three theological virtues of faith, hope and love.

The role of HIV social research in the response efforts to the HIV epidemic in Papua New Guinea.

The underpinning of social research is that people and communities are social beings. Social research thus offers both qualitative and quantitative ways of measuring, describing, explaining and predicting social life. In this paper I explore the role of this paradigm in addressing the HIV (human immunodeficiency virus) epidemic in Papua New Guinea. Specifically I address the value of social research in its ability to ask different questions in and of the epidemic, to increase understanding of the cultural dimensions of HIV infection, including its treatment, and to respond to the changing needs of communities and individuals as a result of changing applications of HIV technology such as HIV testing, as evidenced by provider-initiated counselling and testing. In conclusion I argue that together in partnership both social and biomedical research and their application have the power to change the way that care is provided for the citizens of Papua New Guinea.

Increasing Parental Knowledge Related to the Human Papillomavirus (HPV) Vaccine.

INTRODUCTION: The purposes of this study were to evaluate parental attitudes toward general vaccination protocols and increase parental knowledge of the human papilloma virus (HPV) vaccine. METHODS: A nonprobability convenience sample (N = 75) using a pre-/postintervention study design was conducted in a pediatric office in southern New Jersey. The Parental Attitudes Module measured the general disposition toward having children receive any type of vaccine. The HPV Knowledge Survey was a second tool used to specifically measures knowledge of the HPV vaccine. A self-directed computer-based learning was part of the educational intervention. RESULTS: A paired t test showed that HPV Knowledge Survey postintervention scores were significantly higher than HPV Knowledge Survey preintervention scores (t = -10.585, p < .001). The Parental Attitudes Module and the HPV Knowledge Survey pretest showed a positive moderate relationship (rs = .552, p < .001). DISCUSSION: In the 10 years since the HPV vaccine has been on the market, there is a continued need to increase parental knowledge about the HPV vaccine to close the gap on vaccine nonadherence. A self-directed, computer-based learning tablet appears to be an effective tool to educate parents or legal guardians about the purpose, efficacy, and safety of the HPV vaccine.