Human papillomavirus (HPV) is a type of virus with a double-stranded DNA structure that is among the most frequently occurring sexually transmitted infections. It spreads primarily through sexual contact and affects both the skin’s surface and mucous membranes.

This can lead to the development of common warts on the skin and, in some cases, cervical cancer [1]. While many individuals infected with HPV will naturally rid themselves of the infection over time, those with persistent infections remain at risk for potential complications [1]. Although there are over 140 types of HPV, only about 40 are transmitted through sexual contact. Among these, two high-risk types, HPV 16 and HPV 18, account for over (80%)  of cervical cancer cases in India [2]. Additionally, various clinic-epidemiological risk factors, such as early marriage, multiple sexual partners, frequent pregnancies, inadequate genital hygiene and smoking are frequently linked to the onset of cervical cancer [2].

Cancer stands as one of the primary causes of mortality globally, claiming almost 10 million lives in 2020, equating to roughly one in six deaths. Infections that lead to cancer, such as HPV and hepatitis, contribute to about (30%) of cancer cases in low- and lower- middle-income nations. In 2018, cervical cancer accounted for about (91%) of HPV-related cancers in women worldwide. In 2020, cervical cancer ranked as the fourth most common

cause of cancer-related deaths among women, with an estimated 604,000 new cases and over 340,000 fatalities, constituting (8%) of all female cancer deaths [3]. Low- and middle-income countries (LMICs) contribute to over (90%) of all cervical cancer deaths [4].

Even though WHO recommends it and effective HPV vaccines are available in over 100 countries, India has not yet included the HPV vaccine in its national immunization program. In India there are two types of HPV vaccines: the quadrivalent vaccine (Gardasil TM, Merck, USA, HPV4)—which targets HPV types 6, 11, 16, and 18—and the bivalent vaccine (i TM, GSK Biologicals, Belgium, HPV2)—which targets HPV types 16 and 18. The nine-valent HPV vaccine (Gardasil TM, Merck, USA) is not yet available in India [5].

 In 2014, India decided to incorporate the HPV vaccine into the national immunization program [6]. Currently, the only HPV vaccine available on the private market is Gardasil, which comes at a high cost [7]. In January 2023, the Serum Institute of India launched CERVAVAC, India’s first indigenous vaccine against cervical cancer. Priced at Rs. 2000 per dose, this vaccine will be available in the private market in two-dose glass vials [7]. Considering all these facts, we planned this study to assess the knowledge, attitude and practices regarding HPV vaccination among young female adults accessing health facilities in

this context.

This cross-sectional observational study was conducted over six months from June 2023 to November 2023 at health-care facilities located in the western region of Madhya Pradesh. The study targeted young female adults attending the outpatient department (OPD) of the gynaecology department at the medical college, the Maternal and Child Health (MCH) unit of the District Hospital, the Rural Health and Training Center (RHTC) and the Urban Health and Training Center (UHTC). Informed consent was obtained  from the participants and their parents. The study protocol was approved by the institutional ethical committee with reference number GMC/RATLAM/2023/IEC/Approval/13.

Only participants who provided consent were included, while seriously ill patients incapable of responding were excluded. From a study conducted by Borluv et al. [8] (2016) as a reference “369” is the calculated sample size using the formula [4pq/d2] as per the prevalence of awareness about HPV vaccination (36.1%) We obtained permission from the relevant authorities at the Medical College and its associated sites prior to data collection. The datawas collected from the Medical College (121 participants) and its associated hospitals, including the MCH clinic (124 participants), RHTC (69 participants), and UHTC (62 participants). Informed consent was obtained from the participants and their parents.

The study protocol was approved by the institutional ethical committee with reference numberGMC/RATLAM/2023/IEC/Approval/13. Throughout the six-month period, we collected data for four months, encompassing 99 working days. We surveyed a minimum of four females each day, resulting in a total sample size of 369 participants over the duration of the study. But at the end of duration a total of 376 participants were included in the study. 

Pre designed semi structured questionnaire was used for data collection. This questionnaire reported demographic details and included inquiries pertaining to knowledge, attitudes and practices regarding the HPV vaccine. Socio-economic scale evaluated using BG Prasad scale.  After data collection, we entered the data into Microsoft Office Excel and analyzed it using EpiInfo 7, free software. Qualitative variables described as frequency and percentage.

Participant Demographics

We distributed the 376 participants among four different associated centres. The sample size from each facility was 121(33%), 124 (32.2%), 69 (16.5%), and 62 (18.4%) from Medical College, MCH, RHTC and UHTC, respectively. The majority of participants were female (58.9%) within the 21–24 years age group. (78.3%)  of females were married, while

(28.5%)  were unmarried. Most identified as Hindu (77.65%) and hailed from rural areas (50.7%). A significant portion (26.9%) belonged to lower socioeconomic status (Table 1).

Knowledege related characteristics

Just (10.9%) of participants had heard about HPV infection, primarily from the internet (5.1%). Only (10.1%) knew about the HPV vaccine, and overall, (9.54%) of females had knowledge about HPV infection. (10.1%) believed that HPV infection can cause different types of cancer. Regarding transmission, (14.4%) believed only females can get HPV infection, while (13.8%) believed both males and females can. (7.4%) believed the HPV vaccine can be given to both sexes. (11.7%) believed the HPV vaccine can prevent STDs. (16.2%) believed the appropriate age group for vaccination is 20–30 years, while (13% ) believed it can prevent cervical cancer .(Table 2)

Table 1. Sociodemographic Characteristics of the Study Participants (n = 377)

Attitude related Characteristics

 (23.9%) believed the HPV vaccine is highly effective, and (80.1%) agreed to receive it if provided free of cost by the government. (76.3%) of females expressed readiness to take the vaccine. (73.7%) agreed that doctors’ recommendations influence their decision, while (64.6%) believed parents influence vaccination decisions. (19.7%) agreed they could contract HPV infection in the future, and (42.8%) believed vaccination could protect others (Table 3).

Table No.3 Attitude of participants regarding HPV infection and HPV vaccine.

Table No.4 Practices regarding HPV vaccine.

Table No.4 summarizes responses from 376 individuals regarding HPV vaccination and general vaccine preferences. None had received the HPV vaccine, though 96.5% reported receiving other vaccines. Most were unaware if their partner or sibling had been vaccinated against HPV (40.0%), while 60.0% confirmed they had not. A significant majority preferred getting vaccinated in the government sector (92.5%) over the private sector (7.5%).

The mean age of participants was 21.23 years. A mere (10.9%)  of females had prior knowledge of the HPV vaccine. Our study found that only (0.5% ) of participants recognized males as being affected by HPV, while (14.4% ) acknowledged females, and (13.8%)  understood that both genders could be affected. In contrast, a study by Proma Paul et al. (2014) of parental views on HPVvaccination showed majority support for vaccinating girls and varying opinions on vaccinating boys [9].In our study, (11.7%)  of participants acknowledged the vaccine’s potential to prevent cancers and some STDs. However, contrasting findings emerged from research conducted in Delhi by Singh et al. (2018), where a substantial (38.1%)  of female participants believed in the vaccine’s ability to prevent STDs.  Perceptions of the appropriate age for HPV vaccination varied among different groups. We found that (8.5% ) believed it should be administered between ages 10–20, while another study (n = 61) showed that (16.2% ) preferred ages 20–30. A focus group discussion by Shah et al. (2021) revealed that younger women favoured vaccination at a younger age, while older participants preferred it after 18 years of age. The timing of vaccination is important, and a clear time range should be given to reduce the chances of ambiguity. Beliefs about recovery from HPV infection varied significantly among participants. Only (12%)  expressed belief in complete recovery, while (27.1% ) felt that some cases could fully recover. The majority (60.9%) believed complete recovery from HPV infection is unattainable. In contrast, Petmore Zibako et al. (2021) found that (63.3% ) believed that cervical cancer, often associated with HPV, is curable.  A total (62.2%)  of respondents were unaware of the availability of the HPV vaccine, with only (32.7%)  considering government hospitals as potential sources. In contrast, Chawla.P et al. (2016) reported (81%)  awareness among medical and paramedical staff.  When we surveyed respondents about whether HPV can cause various cancers, our findings revealed gaps in awareness. Only (10.1%)  of respondents recognized the link between HPV and cancer types. Conversely, (3.55% ) incorrectly believed HPV does not cause cancer. Most notably, (86.4% ) of participants admitted they were unaware of this link to cancer. The study revealed that only (13.0% ) of females believe the HPV vaccine can prevent cervical cancer, contrasting sharply with Ataur Rehman et al.’s (2022) study, where about (47.3%)  perceived its protective efficacy.In our study we found that only (23.9%)  of participants believed in the effectiveness of the HPV vaccine, contrasting sharply with a study conducted by Mihretie et al. (2022) in Ethiopia, in which (71.2%)  expressed confidence in its efficacy. This difference suggests that cultural beliefs and societal norms may influence perceptions of vaccine effectiveness. In Ethiopia, where modern medical interventions are increasingly accepted, there may be greater trust in vaccines. Conversely, in India, differing cultural attitudes and socioeconomic factors could contribute to more cautious views. Understanding these dynamics is crucial for targeted vaccination education and promotion efforts.  In our study (19.7% ) of young adult females acknowledged the possibility of acquiring HPV infection, with many uncertain about that likelihood. In contrast, a study among medical, dental and nursing students conducted by Shetty et al. (2019) in South India found that (9.7%)  believed they could easily contract HPV. Factors such as personal experiences, social influences and access to accurate information shaped perceptions among young adult females. In our study, (64.6%)  of participants recognized parental influence in their HPV vaccination decisions, while (73.7%)  considered doctors’ recommendations significant. In contrast, Leung JCT et al. (2018), in a study in Hong Kong, reported lower figures: (51.8% ) for parental influence and (75.9%)  for doctors’ influence. Both studies highlighted the critical role of health-care providers in vaccination decisions, emphasising the need for effective communication strategies to promote vaccine uptake. Among our survey participants, (42.8%)  had a slightly positive attitude towards HPV vaccination, believing it could prevent virus transmission. However, (55.6%)  either expressed uncertainty or lacked sufficient knowledge about the vaccine’s efficacy. While encouraging, these findings highlight the importance of education to address misconceptions and enhance understanding of HPV vaccination benefits. When asked whether the HPV vaccine can be given during serious illness, (14.9% ) of participants incorrectly answered “yes.” However, the majority, comprising (74.7%)  of respondents, responded with “don’t know,” citing a lack of knowledge as the primary reason for their uncertainty. As per the findings of this study, all participants, a total of (100%) , have yet to receive a single dose of the HPV vaccine. Conversely, a study conducted by Swarnpriya et al. (2015) in South India, focusing on medical and paramedical students, reported a contrasting figure. Their findings revealed that (6.8% ) of participants had received the HPV vaccine. This discrepancy highlights a gap in knowledge and awareness that exists outside of medical and health-care professions. A total of (76.6% ) of participants were willing to receive the HPV vaccine, contrasting with Joshi et al.’s (2020) study in western India, where (40.11%)  refused and (32.17%)  were undecided. A striking (96.5%) of participants in this study have received vaccines other than the HPV vaccine, primarily routine immunizations. Comparing this to the National Family Health Survey-5 (NFHS-5) data, which indicate a (77.1%) immunization rate among children in Madhya Pradesh, underscores the robust acceptance of vaccines within the general public in Madhya Pradesh [19]. This high rate of acceptance is encouraging and indicative of a positive attitude towards vaccination in the region. Furthermore, a noteworthy (80.1%)  of our surveyed participants expressed their willingness to receive the HPV vaccine if it were provided free of cost by the government of India. This finding suggests a strong demand for HPV vaccination when financial barriers are removed. In contrast, a 2014 study conducted in Bangalore identified cost (53%) as the primary barrier to vaccination [20].The most common source of information about HPV infection was the internet, cited by (5.1%)  of participants. This contrasts with a study conducted by Pandey et al. (2012) among medical students, where medical school teaching emerged as the most common source of information (42.9%), followed by the internet (29.9%), friends (16.8%), newspapers (16.8%), books (14.6%) and television (11.7%). This difference highlights the noteworthy role of the internet as a source of health information among our participants, albeit less prominent compared to medical students. Leveraging internet resources effectively could enhance public awareness and understanding of HPV-related issues. If the vaccine were included in the National Immunization Schedule (NIS) and provided free of cost, as suggested by our participants’ willingness, that could potentially bridge the gap in HPV vaccine coverage.

Limitation

The study was solely conducted in the age group of young female adults between 15-24 years. If this study covered wider range groups, the finding may be different pertaining to practice. The broad age group with random sampling in a larger area could be approached in KAP study.

Recommendation  

Promote comprehensive educational campaigns to raise awareness about HPV infection, its associated health risks, and the importance of vaccination among the public and healthcare providers. Implement accessible vaccination programs in schools, community health centers, and other convenient locations to ensure equitable access. Address vaccine hesitancy through clear communication about safety and efficacy, alongside dispelling myths. Integration into national immunization programs can enhance uptake and contribute to preventing HPV-related diseases, supported by efforts from health professionals and e-media.

Despite the significant gap there is optimism due to their positive attitude towards vaccination. With the launch of a free vaccination program, the government aims to achieve widespread acceptance and participation from this demographic. Bridging the awareness-action divide promises a healthier, more informed community, effectively combating HPV. Addressing these challenges requires targeted education, improved vaccine accessibility, and policy interventions for affordability, aiming to prevent cervical cancer and enhance rural healthcare outcomes.

Acknowledgement

A profound gratitude to MBBS students  Rama Garg, Pravin Patel, Kavita Chiraniya, Shalu Kailasya, Piyush Priya, Karnika Chauhan and Roshan Patidar from Batch-2018 of the Department of Community Medicine. Their dedication and contributions enriched research endeavor significantly. We sincerely thank all interns for their indispensable role in our scholarly pursuits.

Financial support and sponsorship

Not applicable

Conflict of interest

No conflicts of interest

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