The Effectiveness of a Facebook-Assisted Teaching Method on Knowledge and Attitudes About Cervical Cancer Prevention and HPV Vaccination Intention Among Female Adolescent Students in Taiwan

Abstract

Background. Lack of education is a known barrier to vaccination, but data on the design and effectiveness of interventions remain limited. Objective. This study aims to identify the effectiveness of a Facebook-assisted teaching method on female adolescents’ knowledge and attitudes about cervical cancer prevention and on their human papillomavirus vaccination intention. Method. A quasi-experimental time series research design was used. Two hundred female adolescents at a senior high school in Taipei were recruited into two groups. Following a classroom lecture, one group was provided a Facebook-assisted online discussion, and the other group was provided an in-person discussion forum. A demographic questionnaire and cervical cancer prevention questionnaire were distributed. Data were analyzed for descriptive statistics and generalized estimation equations. Results. Improvement from T0 to T2 in knowledge and attitude scores was 4.204 and 4.496 points, respectively. The Facebook group’s improvement in vaccination intention from T0 to T2 was 2.310 times greater than the control group’s improvement under conditions of out-of-pocket expenses and 2.368 times greater under conditions of free vaccination. Conclusions. School-based cervical cancer prevention education can be effective. The Facebook-assisted discussion method was more effective than the in-person discussion. Providing the human papillomavirus vaccine free of charge would increase female adolescents’ intention to be vaccinated.

Keywords

adolescents attitudes cervical cancer Facebook human papillomavirus (HPV)knowledge vaccination intention

Having safe sex skills and receiving a human papillomavirus (HPV) vaccine before onset of sexual activity are the most efficient methods to prevent HPV infection and cervical cancer (Harper et al., 2006). However, there are limited opportunities for female high school students to acquire cervical cancer prevention education (CCPE). This results in insufficient HPV knowledge (Cooper Robbins et al., 2010; Kwan, Tam, Lee, Chan, & Ngan, 2011; Marek et al., 2011; Woodhall et al., 2007). Tang, Liu, Li, Cai, and Wan (2014) indicated that opportunities for CCPE in adolescence come primarily from television and radio broadcasts (59.3%); the smallest amount of CCPE comes from health professionals (20.9%) and schools (18.6%). School nurses or nurse teachers should reinforce more effective CCPE in high school students (Tang et al., 2014). In order to enhance female adolescents’ knowledge and attitudes toward cervical cancer prevention as well as to increase their HPV vaccination intention, it is important to conduct school-based CCPE that is effective and highly accepted by female adolescents.

Literature Review

Introduction of HPV

Cervical cancer is the sixth leading cause of death in women and the second most frequently observed cancer in women aged 15 to 44 in Taiwan (Ministry of Health and Welfare, 2013). HPV, which is easily transmitted by sexual contact, has been confirmed as a necessary instigator in 99% of all cervical cancer cases (Gunther et al., 2008). HPV is usually acquired within the first few years following an onset of sexual activity, with peak incidence typically occurring between the ages of 16 and 20 years (World Health Organization, HPV Vaccine Advisory Committee, 2008). One 2.2-year longitudinal study indicated that the cumulative prevalence of HPV infection in adolescent girls aged 14 to 17 exceeded 80% (Brown et al., 2005). Despite a high prevalence of HPV cases, the viral infection clears within 5 years without treatment in 80% to 90% of immune-competent women; women who have a persistently infected cervix and cannot clear the infection have a two- to threefold increased risk of developing cervical cancer (Myers, McCrory, Nanda, Bastian, & Matchar, 2000; Richardson et al., 2005).

Adolescents and the HPV Vaccine

A comprehensive cervical cancer control program involving HPV vaccination of adolescent girls has been proven the most cost-effective approach to reducing the burden of cervical cancer (Basu, Banerjee, Singh, Bhattacharya, & Biswas, 2013). In 2006, the United States became the first country to approve the HPV vaccine for females aged 9 to 26 (Gunther et al., 2008). It is recommended that adolescent girls receive the HPV vaccine before they become sexually active (Bonanni et al., 2011). Nevertheless, in Taiwan, less than 4% of eligible girls and women have been vaccinated, a state of affairs that remains a major public health challenge (Chow et al., 2010). One of the main reasons for the low vaccination rate is the lack of government support for a free HPV vaccine targeting the most vulnerable demographic population (Chan, Chan, Ng, & Wong, 2012; Chow et al., 2010). In 2007, Kinmen County, one of few counties providing free vaccines in Taiwan, established a 3-year school-based and free HPV vaccination program that targeted all female residents aged 16 to 18. By 2010, the uptake rate dramatically increased to more than 90%, demonstrating that the free school-based program was an effective approach (Lee, Chen, Wu, & Huang, 2012). Other barriers affecting HPV uptake rates include insufficient knowledge about cervical cancer prevention, parental acceptance, vaccine efficacy, and concerns over vaccine safety (Chan et al., 2012; Marlow, Waller, Evans, & Wardle, 2009; Waller, Marlow, & Wardle, 2006).

Adolescents and Online Social Networks

Among adolescents, social networking services (SNSs) have grown rapidly in popularity. The interactive functions of SNSs offer an innovative communication environment that fosters health promotion intervention among adolescents (Gold et al., 2011; Loss, Lindacher, & Curbach, 2014). Students and teachers increasingly have turned to SNSs for communication and information exchange (Goldstein et al., 2013). One study indicated that 85% of students believe SNSs can benefit their learning experience; only 3.5% lack interest in following others on a social networking platform (Maloney, Moss, & Ilic, 2014).

Facebook is the most frequently used SNS (Gold et al., 2011). Previous studies have demonstrated that Facebook has great usability for health promotion and high acceptability for providing disease and vaccine information (Gold et al., 2011; Mena et al., 2012). Facebook provides public and private messaging communication and information exchange, making it a suitable platform for student discussions about sensitive health issues such as cervical cancer prevention (Gold et al., 2011). Facebook also compensates for the disadvantages of face-to-face discussions, which can be time-consuming, stressful (such as when facing teachers), or embarrassing (such as when asking sensitive questions). Additionally, Facebook carries the advantages of rapid transmission (Ergun, Eyigor, Karaca, Kisim, & Uslu, 2013; Vance, Howe, & Dellavalle, 2009), use of multiple digital media (photos, videos, and content sharing), live-updated information announcements, and entertainment (Gold et al., 2011; Goldstein et al., 2013).

Theoretical Framework

The CCPE program’s design was based on the health belief model. One of the model’s tenets is that individual’s vaccination intention could be enhanced by improved knowledge and attitudes through health education (Janz & Becker, 1984). Other variables of health belief model constructs, including attitudes of perceived susceptibility, seriousness, benefits, and barriers, were collected and will be further analyzed in another study. The aim of this research was to identify the effectiveness of a Facebook-assisted teaching method for school-based CCPE on knowledge and attitudes about cervical cancer prevention and on HPV vaccination intention among female students in a senior high school in Taiwan.

Method

Research Design

A quasi-experimental time series research design was used, with purposive sampling of a control group and an experimental group. Data were gathered at three separate time points (pretest, Posttest 1, Posttest 2).

Setting

The study was conducted at a large senior high school in Taipei from September to December 2012. Participants of the experimental group were required to have a computer or mobile device that could access Facebook discussion sessions.

Sample

In this study, 4 of 16 Grade 1 classes participated, with 50 female students allocated to each class. Two classes were randomly assigned to the control group, while the other two classes held the experimental group. To meet the study’s inclusion criteria, participants needed to be (a) literate and able to communicate in Mandarin, (b) capable of understanding the study purpose, and (c) female students aged between 15 and 17 years.

Teaching Materials and Teaching Strategies

The CCPE was developed by the Ministry of Health and Welfare to assist teens in understanding cervical cancer, Pap smear screening, HPV vaccination, and cervical cancer prevention. The lecturer, a nursing teacher, initiated the discussion with the question: What is an HPV vaccine? This was followed by a brief introduction of the HPV vaccine and the CCPE lecture commenced. The lecture concluded with a brief summary and discussion, reflecting on the importance of cervical cancer prevention. Six-hour discussion sessions were offered either with Facebook-assisted or in-person discussions after class. No additional questions or information were distributed in the discussion sessions.

Procedures

Study conduct approval was obtained from the research ethics office. After explaining the research purpose to study participants, a written consent form was obtained. Participating students were asked to complete the demographic questionnaire (DQ) and cervical cancer prevention questionnaire (CCPQ), at T0, prior to the 50-minute in-class lecture on cervical cancer prevention. During the 2 weeks following the classroom CCPE lecture, participants entered optional discussion sessions (either Facebook-assisted or face-to-face). Attendance to such forums was optional. Posttest 1 was performed at T1, 2 weeks after T0, and posttest 2 was performed at T2, 8 weeks after T0.

Participants anonymously filled out hard copies of all questionnaires, which were then sealed and sent to the Research Consultation Office. The Office entered the data into a Microsoft Excel file and provided the data to the researchers for further analysis.

Instruments

Demographic Questionnaire

The DQ requested participants’ age, socioeconomic status, parents’ education, sexual experience, age at onset of sexual activity, number of sexual partners, and frequency of using Facebook.

Cervical Cancer Prevention Questionnaire

The CCPQ, named by this research team, was revised from the questionnaire previously developed by L. F. Wen. It has acceptable reliability and validity: The content validity index was 97.62%, the Kuder-Richardson Formula 20 (KR-20) was .67, and Cronbach’s alpha was .66 (Wen & Chang, 2007). The reliability and validity of the CCPQ in the current study were also assessed. Cronbach’s alpha was found to be .81, and expert validity was .99, both of which were acceptable for the instrument. Four experts were invited to examine the relevance and accuracy of items and the appropriateness of the questionnaire wording. One expert was an assistant professor of a nursing department specializing in pediatric nursing, one expert was an obstetrician in a medical center, one expert was a school nurse in a large senior high school, and one expert was a head nurse in an obstetrics ward at a community-based hospital.

The CCPQ consisted of two subscales and two conditional questions. The two subscales were the 20-item Knowledge of Cervical Cancer questionnaire (KCCQ) and the 20-item Attitude of Cervical Cancer questionnaire (ACCQ), both of which measure knowledge and attitudes about cervical cancer prevention. The two individual conditional questions measured HPV vaccination intention under conditions of the vaccination being “free of charge” or an “out-of-pocket expense.” Details are described below.

Knowledge of Cervical Cancer Questionnaire

The KCCQ is a 20-item standardized self-reported scale written in Chinese. It consists of four parts, including a five-item section on cervical cancer, a five-item section on Pap smear screening, a five-item section on HPV vaccination, and a five-item section on cervical cancer prevention. Each item in the KCCQ is designed in the form of a true/false question. Three options, correct, wrong, and not sure, are provided for each item. Participants were required to check one of the responded answers for each item. A correct answer received a score of 1 point. An incorrect answer or a not sure would result in 0 points. The total score ranged between 0 and 20, with higher scores representing greater knowledge about cervical cancer.

Attitude of Cervical Cancer Questionnaire

The ACCQ is a 20-item self-report scale with a 5-point Likert-type rating. It consists of four parts, a five-item section on “perceived susceptibility,” a five-item section on “perceived seriousness,” a five-item section on “perceived benefits,” and a five-item section on “perceived barriers.” Each item was scored from 1 (disagree) to 5 (agree). Scores ranged from 20 to 100. Higher scores reflected more positive attitudes toward HPV prevention.

Two conditional questions about HPV vaccination intention

Two conditional questions about cost were asked regarding “out-of-pocket expense” versus “free of charge.” Each question was in the form of choice to vaccinate. Three options, yes, no, and not yet decided, were provided for each question. A yes counted as 1, and no or not yet decided counted as 0.

Data Analysis

Data were exported from a Microsoft Excel database into SPSS version 19.0 for analysis. Descriptive statistics were used to describe demographics and variables. Independent t tests and odds ratio were used to examine differences between the experimental and control groups. A generalized estimating equations (GEE) model was used to identify the difference in improvement of female students’ knowledge, attitudes, and vaccination intention between the two teaching methods.

Results

Demographic Characteristics

As shown in Table 1, 200 students (100%) agreed to participate in this study. The results indicated that there were no demographic differences between the experimental and control groups. The mean age of participants was 15.35 years. The majority (n = 187, 93.5%) of female adolescents reported a lack of sexual experience. Among the students who had sexual experience, the mean age of sexual activity onset was 14.93, and the number of sexual partners was 1.38. Almost three quarters of participants (72%) used Facebook at least once a day, and 42.5% used Facebook several times a day.

Table 1.

Demographic Characteristics.

	All groups (N = 200)		Control group (n = 100)		Experimental group (n = 100)
Variables	n (%)	M ± SD	n (%)	M ± SD	n (%)	M ± SD	t	χ²/F	p
Age		15.35 ± 5.35		15.39 ± 5.39		15.31 ± 5.31	−1.18		.238
Family socioeconomic status								1.100	.294
Poor	67 (33.5)		37 (37.0)		30 (30.0)
Average	133 (66.5)		63 (63.0)		70 (70.0)
Father’s education								2.961	.228
Less than junior high school	37 (18.5)		23 (23.0)		14 (14.0)
High school degree	105 (52.5)		48 (48.0)		57 (57.0)
College degree	58 (29.0)		29 (29.0)		29 (29.0)
Mother’s education								1.173	.556
Less than junior high school	39 (19.5)		22 (22.0)		17 (17.0)
High school degree	107 (53.5)		50 (50.0)		57 (57.0)
College degree	54 (27.0)		28 (28.0)		26 (26.0)
Sexual experience								0.740	.390
Yes	13 (6.5)		8 (8.0)		5 (5.0)
No	187 (93.5)		92 (92.0)		95 (95.0)
Age at onset of sexual activity		14.93 ± 0.56		14.87 ± 0.35		15.00 ± 0.00	0.77		.453
No. of sexual partners		1.38 ± 0.64		1.37 ± 0.74		1.40 ± 0.54	0.65		.950
Frequency of Facebook use
Never	9 (4.5)		4 (4.0)		5 (5.0)
Seldom	47 (23.5)		23 (23.0)		24 (24.0)
Once a day	59 (29.5)		30 (30.0)		29 (29.0)
Several times a day	85 (42.5)		43 (43.0)		42 (42.0)

Students’ Responses

In the experimental group, 72 out of 100 students entered the discussion sessions. In general, the participants discussed CCPE-related topics without obstacles or interventions. Of the participants, five students asked subject sensitive questions via private messaging. In the control group, only 7 of 100 students asked questions that were less sensitive, such as “How effective is the HPV vaccine?” and “What are the pros and cons of the HPV vaccine?”

Independent t Test

There was no significant difference between groups at T0 on KCCQ scores (t = −0.572, p = .568) or ACCQ scores (t = −0.495, p = .621). As depicted in Table 2, significant differences were found at T1 and T2 in both KCCQ scores (t₁ = −5.484, p₁ = .000; t₂ = −8.025, p₂ = .000) and ACCQ scores (t₁ = −4.546, p₁ = .000; t₂ = −5.119, p₂ = .000).

Table 2.

Descriptive Statistics of Knowledge and Attitude of Cervical Cancer, and HPV Vaccination Intention.

	T0				T1				T2
CCPQ subscales	Ctrl (M ± SD)	Exp (M ± SD)	t/OR	p	Ctrl (M ± SD)	Exp (M ± SD)	t/OR	p	Ctrl (M ± SD)	Exp (M ± SD)	t/OR	p
KCCQ	7.94 ± 3.48	7.64 ± 3.92	−0.572	.568	12.42 ± 3.97	15.06 ± 2.71	−5.484	.000***	12.39 ± 4.36	16.29 ± 2.12	−8.025	.000***
ACCQ	60.33 ± 7.14	60.88 ± 8.50	0.495	.621	61.61 ± 7.47	66.09 ± 6.42	−4.546	.000***	61.86 ± 7.11	67.00 ± 7.08	−5.119	.000***
Intention
Out-of-pocket			0.786	.396			1.810	042*			1.847	.039*
Free-of-charge			1.049	.877			2.068	.060			2.531	.046*

Note. CCPQ = Cervical Cancer Prevention Questionnaire; Ctrl = control group; Exp = experimental group; KCCQ = Knowledge of Cervical Cancer Questionnaire (subscale); ACCQ = Attitude of Cervical Cancer Questionnaire (subscale); OR = odds ratio.

p < .05. ***p < .001.

Odds Ratio

Under the condition of the vaccine being an out-of-pocket expense, students receiving a Facebook-assisted teaching method were 1.810 and 1.847 times more likely to have the intention to be vaccinated compared with students who received traditional teaching instruction at T1 (odds ratio [OR] = 1.810, p = .042) and T2 (OR = 1.847, p = .039). Under the condition of receiving the vaccine free of charge, this figure was 2.531 times higher at T2 (OR = 2.531, p = .046).

GEE

A GEE model was used to compare differences in improvement. Results are presented in Table 3. The tendency toward improvement is shown in Figures 1 and 2.

Table 3.

GEE Analysis.

	Knowledge		Attitudes		Out-of-pocket expense		Free of charge
Group after interaction with time	β	p	β	p	Exp(β)	p	Exp(β)	p
(Posttest 1/Pretest)	2.942	<.001***	3.888	.010***	2.284	<.001***	1.958	.033*
(Posttest 2/Posttest 1)	1.262	.047*	.608	.103	1.011	.915	1.209	.528
(Posttest 2/Pretest)	4.204	<.001***	4.496	.004***	2.310	<.001***	2.368	.046*

p < .05. **p < .01. ***p < .001.

Figure 1.

Knowledge of Cervical Cancer Questionnaire scores at T0, T1, and T2.

Figure 2.

Attitude of Cervical Cancer Questionnaire scores at T0, T1, and T2.

Knowledge

A comparison of change from T0 to T1 across groups indicates that knowledge improvement scores in the experimental group were 2.942 points greater than those in the control group (β = 2.942, p < .001). Changes from T1 to T2 were 1.262 points greater (β = 1.262, p = .047). In total, we observed 4.024 points in improvement.

Attitudes

Attitude improvement scores in the experimental group were 3.888 points greater than those in the control group from T0 to T1 (β = 3.888, p = .010) and .608 points greater from T1 to T2 (β = 0.608, p = .097). There was a total of 4.496 points improvement.

Vaccination Intention

Under the condition of the vaccine being an out-of-pocket expense, the experimental group’s improvement scores from T0 to T1 were 2.284 times greater than those scores in the control group (β = 2.284, p < .001). From T1 to T2, improvement scores in the experimental group were 1.011 times greater (β = 1.011, p < .915). In total, we observed improvement of 2.310 times.

Under the condition of receiving the vaccine free of charge, scores of improvement from T0 to T1 were 1.958 times greater in the experimental group than those scores in the control group (β = 1.958, p = .033). From T1 to T2, improvement scores were 1.209 times greater in the experimental group (β = 1.209, p = .528). In total, we observed improvement of 2.368 times.

In conclusion, our results confirm that the Facebook-assisted teaching method significantly enhanced knowledge, attitudes, and HPV vaccination intention to a greater degree than did traditional teaching methods.

Discussion

To the best of our knowledge, this is the first study to use a private Facebook group as a discussion setting to facilitate cervical cancer prevention among female adolescent students. The results indicate that the Facebook-assisted teaching method is superior to the traditional teaching method in facilitating female adolescents’ knowledge and positive attitudes toward cervical cancer prevention and in improving HPV vaccination intention.

Facebook has been regarded as an appropriate platform for adolescents’ health promotion education; facilitators can raise a health-related issue on Facebook to foster desired health behaviors, and then exchange ideas about health with online members (Loss et al., 2014). There are several possible reasons why a Facebook-assisted teaching method may be more effective. First, Facebook offers a more interactive environment and novel methods to engage with one another, which may appeal to adolescents to continue discussions after class. Second, Facebook may decrease students’ embarrassment about discussing sensitive issues. Adolescents tend to discuss sexual health issues via messaging (Byron, Albury, & Evers, 2013). Third, Facebook addresses adolescents’ concerns about privacy. Within the private Facebook group, students can decide how much they want to share and can create their own content by either responding to others publicly or asking personal questions via private messages. Fourth, Facebook can improve communication speed and accessibility (Maloney et al., 2014). Fifth, friend “likes” can accelerate adolescents’ identification of the value of CCPE. Adolescents usually click the “like” button to signify a feeling of commonality, which indicates social sanctioning (Loss et al., 2014).

This study confirmed the effectiveness of the school-based CCPE on improving knowledge and attitudes about cervical cancer prevention and HPV vaccination intention among female adolescents in Taiwan during the 2-month follow-up period in both groups. This is consistent with previous findings regarding school-based CCPE that have been found to positively affect female adolescents’ knowledge, attitudes, and HPV vaccination intention (Gottvall, Tyden, Hoglund, & Larsson, 2010; Kwan et al., 2011; Marek et al., 2012). However, how individual teaching strategies (discussion sessions or classroom lecture) contributed to the observed effects was not determined because of the lack of observations immediately following the classroom lecture.

As expected, adolescents had significantly higher intention to be vaccinated given the condition that the vaccine is free of charge. This highlights the importance to primary prevention of routinely offering free or co-paid HPV vaccines, as well as the school-based CCPE, to eligible female adolescents. This finding is consistent with prior studies that reveal how female adolescents have high intention of HPV vaccination through a school-based educational program (Chan et al., 2012; Kwan et al., 2011). Ideally, health education can affect HPV vaccination behavior; however, intention does not always translate into action. The “knowledge–behavior gap”—that is, the difference between people’s knowledge and their actual health behavior—and parental acceptance may explain this phenomenon (Wegwarth, Kurzenhauser-Carstens, & Gigerenzer, 2014).

Wegwarth’s study is conducted to identify differences between HPV vaccination intention and actual HPV vaccination behavior (Wegwarth et al., 2014). One interesting observation is the decrease in intention to have the HPV vaccine among members of the balanced leaflet group and the increase in intention to have the HPV vaccine among members of the unbalanced leaflet group. The observed difference in intention does not signify a difference in actual vaccination uptake behavior. The knowledge-behavior gap more likely exists if people are presented with unbalanced rather than balanced health information. In addition, for children younger than 18 years of age, respective parents are the primary decision makers concerning HPV vaccination behavior. Parental acceptance will be crucial in ensuring a high uptake (Marlow et al., 2009; Waller et al., 2006). Knowledge about HPV is identified as one of the main predictors of greater vaccine acceptance (Chan et al., 2012; Kessels et al., 2012). It is important but overlooked to educate parents about cervical cancer prevention and the effectiveness of HPV vaccination. Clear communication avenues with parents will ensure that parents understand the reasons for vaccinating adolescent girls and therefore help adolescents and parents making informed vaccination decisions.

Study Limitations

Because of limitations in time and funding, this study recruited a sample group at one senior high school. We only investigated HPV vaccination intention, not HPV vaccination uptake. Moreover, this study did not cover the whole vaccination age demographic from 9 to 26 years of age. Findings may not be generalizable to all female adolescents who are eligible for HPV vaccine uptake.

Dorman indicates that Type I error rates inflate greatly as the intraclass correlation coefficient (ICC) increases for group randomized trials in classroom environment; examining the ICC is recommended (Dorman, 2008). However, no personal information, including class information, was collected for the purpose of anonymity, which made it impossible to examine ICC because of a lack of class information that students belonged to.

Implications and Suggestions

In asserting the importance of cervical cancer prevention and safe sex for female adolescents in senior high schools, the 50-minute standardized CCPE lecture combined with Facebook-assisted discussion is likely to be more effective than in-person discussions. Through a CCPE program evaluation meeting, the authors concluded that the content of CCPE discloses unbalanced information regarding the safety of the HPV vaccine. All possible serious or nonserious adverse events are not presented in these materials, such as local site reactions, dizziness, nausea, headache, hypersensitivity reactions, and death (Slade et al., 2009). A refinement of the CCPE is recommended, especially in its sections pertaining to adverse effects.

Given that the age recommended to be vaccinated is 9 to 26 years, a wider population should be targeted for CCPE. Respective parents should be targeted for CCPE as well. The vaccination completion rate may rise if the CCPE coverage rate increases and if the HPV vaccination program can receive partial or full funds from the government. Further study of the long-term impact and direct changes in HPV vaccine uptake will also be necessary.

It was observed that KCCQ and ACCQ scores in the experimental group remain significantly higher than those in the control group at least 8 weeks after classroom lecture. Further research should examine how long these results persist. This information can be used to provide health care providers a reference in determining when to reboot the CCPE.

Adding an additional observation immediately after finishing classroom lecture is recommended to determine whether classroom lecture or discussion sessions generates better contributions.

It is suggested that we collect class information for performing the analysis of ICC to detect if the Type I error occurs. Besides, to have sufficient power, more than 8 to 10 practices per intervention arm are recommended (Murray, Varnell, & Blitstein, 2004).

Conclusion

Schools and school-based CCPE play an important role in assisting female adolescents to acquire HPV vaccine and self-protection skills. This study confirms that the one-time 50-minute lecture combined with a 6-hour Facebook-assisted discussion can enhance female students’ cervical cancer prevention knowledge and attitudes, resulting in higher HPV vaccination intention than the effects of a traditional in-person discussion method.

Footnotes

Acknowledgements

The authors would like to express their thanks to all participants for their time and efforts in sharing their experiences. Many thanks to all the staff of the Research Center for Health Data, National Taipei University of Nursing and Health Sciences, for their statistics consultation.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

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