Knowledge, Attitude, and Practices of Human Papillomavirus Vaccination among Parents

INTRODUCTION

Human papillomavirus (HPV), a small, non-enveloped deoxyribonucleic acid (DNA) virus, is highly transmissible and is primarily transmitted by sexual contact. Among the 200 serotypes discovered, 15–20 are oncogenic. About 99.7% of all cervical cancer cases demonstrate oncogenic HPV DNA with a lag period of 15–20 years from infection to invasive cancer disease.^[1] In India, the most common prevalent genotypes as a cause of cervical cancer in women are 16 and 18. Non-oncogenic HPV serotypes 6 and 11 contribute to over 90% of benign genital infections such as genital warts.

According to Catalan Institute of Oncology (ICO) and the International Agency for Research on Cancer (IARC) HPV Information Center recent data,^[2] cancer of the cervix uteri is the 4^th most common cancer among women worldwide, with an estimated 604,127 new cases and 341,831 deaths in 2020. Worldwide, mortality rates of cervical cancer are substantially lower than incidence, with a ratio of mortality to incidence of 57%. About 123,907 new cervical cancer cases are diagnosed annually in India, and it ranks as the 2^nd leading cause of female cancer in women aged 15–44 years in India.

Cervical cancer is essentially a preventable disease when detected in the precancerous stage. With the evolution and practice of screening tests, early detection is possible and there is a considerable reduction in mortality. To further prevent mortality and morbidity, vaccines will be of great help.

HPV vaccination is a revolutionary approach to the primary prevention of cervical cancer. Quadrivalent and nonavalent vaccines against oncogenic and non-oncogenic strains of HPV are available in the market. In India, Quadrivalent vaccines are available for females aged 9–45 years, and nonavalent vaccines are available for boys aged 9–14 years and girls aged 9–26 years.

The HPV vaccines are of public health importance. The World Health Organization states that the HPV vaccine should be included in national immunization programs.^[3] This is especially so in countries like India having considerable disease burden but without a screening program. All three licensed HPV vaccines (bivalent, quadrivalent, and nonavalent) have excellent safety, efficacy, and effectiveness profiles.^[4]

MATERIAL AND METHODS

A prospective cross-sectional questionnaire survey was conducted among parents of children aged 0–18 years of age attending the pediatric outpatient department in the month of May to June 2024.

RESULTS

Out of the 160 parents participated in the study, 68% were mothers, and the rest were fathers. About 67.5% of the population lived in the city, while the remaining lived in areas outside the city. About 72% of the population were well educated who at least had a bachelor’s degree or higher, and 10% of the population had attended only primary school. Half of the study participants were parents of female children; one-fourth had male children, and the remaining had both male and female children.

More than half (53%) of the study participants were parents of eligible kids, defined as children more than 9 years who are eligible to get vaccinated, as shown in Figure 1.A majority (56.9%) acknowledged having heard of cervical cancer, while 25% were unaware of it and 18.1% were unsure. Knowledge about cervical cancer transmission through sexual contact was limited, with only 22.5% correctly identifying this mode of transmission, while 40% believed otherwise and 37.5% were unsure. Awareness of the relationship between cervical cancer and HPV stood at 37.5%, indicating a significant portion (62.5%) either did not know this connection or were uncertain. Despite this, a notable 50.6% believed that cervical cancer is preventable by vaccine, yet 33.1% were unsure. Awareness of HPV vaccines was moderate, with 54.4% aware of their existence. Opinions on the necessity of HPV vaccination for children were split, with 49.4% in favor, 15.6% against, and 35% unsure. Knowledge of HPV affecting boys was limited, with only 20% aware, while 49.4% were unsure. Similarly, opinions on boys needing the HPV vaccine were divided, with 22.5% supporting the idea, 40% opposing it, and 37.5% uncertain [Table 1].

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Figure 1:

Sex distribution of eligible kids.

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The survey results indicate varying attitudes toward HPV vaccination across different scenarios, as depicted in Table 2. A significant majority, comprising 87% of respondents, expressed willingness to pay for and receive the HPV vaccine, reflecting a positive inclination toward vaccination. Similarly, 85.5% indicated that they would vaccinate if it were free, reinforcing a strong overall positive sentiment toward vaccination efforts. The positive response rate for vaccinating a girl child stood at 61.9%, which is higher when compared to the 40% positive response rate for vaccinating boys. Notably, 73.3 % disagreed with the notion that only sexually active women should be vaccinated, emphasizing broader supports for universal vaccination strategies. Interestingly, 82.5% expressed a willingness to learn more about HPV and vaccination, indicating a potential for increased awareness and education efforts to further promote vaccination uptake.

Surprisingly, nearly half of the eligible children (51.7%) were vaccinated, out of which 8.3% of males and 91.7% of females were vaccinated, as shown in Figure 2. Parents were more likely to vaccinate their daughters against HPV than their sons (P < 0.001). This version clarifies the percentages and the significance of the gender difference in vaccination rates.

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Figure 2:

Vaccination among eligible kids.

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DISCUSSION

The survey on awareness and knowledge regarding cervical cancer and HPV vaccination revealed mixed levels of understanding among respondents. Our study showed that 56.9% have heard of cervical cancer, and 50.6% believed that vaccines could prevent it. This is almost similar to the findings conducted in Puducherry by Siddharthar et al.^[6], where 44.5 % of the women were aware of cervical cancer, whereas in a study conducted in the rural population of Kerala, almost three-fourths of the study population was aware of cervical cancer and its screening.^[7] In contrast, studies conducted in certain parts of India conclude that the awareness regarding cervical cancer and its vaccine is far behind.^[6-9]

A study conducted by Kumari et al.^[10] in UP has showed a very low level of awareness, with only 8.07% of participants having heard of HPV infection and 2.08% of participants having HPV vaccine knowledge; it could possibly be attributed to the lower level of educated population in that part of our country, whereas our study population is highly educated.

Only 20% of the parents were aware of the fact that HPV can infect boys and vaccines are available to prevent it, which is in concordance with the study conducted by Hong Xie et al.^[11]

In our study, we found a remarkably high level of willingness to vaccinate, exceeding 80%, which is far better than the pooled prevalence of 0.45 noted in the meta-analysis of HPV vaccination awareness in India conducted by Pal et al.^[9] More than 80% of the parents were willing to vaccinate the child even if they must pay for the vaccine or if it is free. This contrasts with studies done in various parts of India, where the majority of the population were willing to vaccinate only if it was free of cost.^[8,11] This high acceptance rate among the surveyed population may be due to the higher educational standards, socio-economic standards, and the awareness among them. In a study, Charakorn et al. found that despite poor knowledge, the acceptability of the HPV vaccine was high among the participants.^[12]

Although people are aware of HPV infection and cervical cancer risk among females, they are unaware of the fact that boys can also be affected, and they must be vaccinated, showing a lower level of willingness to vaccinate boys compared to girls. Similar to our study, Xie et al.’s study conducted in China has shown that parents were more likely to vaccinate their daughters against HPV than their sons^[11] (P < 0.001).

This is probably due to the lack of awareness and reduced availability of vaccines for boys.

It is notable that 82.5% showed openness to gaining further knowledge about HPV and its vaccination, highlighting the potential for heightened awareness campaigns to increase vaccination rates. It was reported that, counseling and information by health care providers increased the acceptance of HPV vaccine in a study done by Basu and Mittal in Kolkata.^[13]

In a systematic review and meta-analysis done by Pal et al.^[9] the overall pooled proportion of HPV vaccine uptake was only 4% with a 95% CI of 2–7%. Our study had an excellent uptake rate of 56% which reflects the educational status and awareness among the studied population. The low uptake rate among boys (8%) emphasizes on our responsibility to create awareness regarding vaccination in males.

CONCLUSION

These findings underscore the need for enhanced education and awareness campaigns to address gaps in understanding about cervical cancer, HPV transmission, and vaccination benefits among the public.

The need for vaccination in male children and its availability should be taken to the public.

It’s essential to advocate for the inclusion of HPV vaccination in national immunization programs. This step can effectively reduce cervical cancer rates and mortality rates..