Knowledge, attitude, and practice on HPV vaccination among pre-university female students

Introduction

Human Papilloma Viruses (HPV) are double-stranded DNA viruses with a great affinity for the squamous epithelium of the genital tract. 1 The prevalence of HPV infection varies from 2 to 44% amongst women and is the most common sexually transmitted disease in adolescents and young women. 2 These viruses are responsible for 99% of cervical cancers and 90% of genital warts worldwide. 3, 4 Cervical cancer is the second most common malignancy in women in India with an annual crude incidence rate of 14.9 per one lakh women population. 5, 6 Carcinoma cervix accounts for more than 5,00,000 cases and 3,00,000 mortality worldwide which makes it a major global disease of concern. 7   

When administered in girls of 15 to 26 years of age, the HPV vaccination is effective against high-grade cervical lesions. The clinical protection and protective antibody titer were sustained over eight to 10 years. 8 Despite the availability of the HPV vaccine in our country, mortality secondary to cervical cancer is still high. The cost of the vaccine, safety concerns, limited knowledge, acceptance, and lack of awareness are the major barriers to HPV vaccine administration in India. 9 Hence, a study was conducted to identify the knowledge, attitude, and practice of the HPV vaccine in pre-university female students. The study also included a comparison between the female students in the urban area to that in the rural area as we know that the economic level, cultural practices, and physical environment affect the attitudes and beliefs of people regarding disease prevention, pathogenesis, and treatment. 10

Materials and Methods

A cross-sectional study was conducted in the Tumkur district of India amongst female students studying in pre-university colleges. Ethical committee approval was obtained from Institute Ethics Committee. A few colleges were selected randomly in urban and rural areas of the Tumkur district. Permission was obtained from the Principals of respective institutes and consent was obtained from the study participants. A pretested questionnaire was shared with the female students and was collected back after it was filled by them. Utmost care was taken to protect the identity of the study participants.

The data collected included demographic factors such as age, class of study, education qualification of parents, socio-economic status, religion, and persons living in the same house. Clinical history such as the family history of malignancy, menstrual hygiene, premarital sex, knowledge, attitude, and practice about HPV was also collected.

The Socioeconomic status was classified based on the revised BG Prasad classification based on the current Consumer Price Index for Industrial Workers (CPI-IW) compiled and released by the Ministry of Labour and Employment, Government of India. 11 Parents’ occupations were classified based on the National classification of occupations 2015 compiled and released by the Ministry of Labour and Employment (Government of India) and the Labour Bureau of Government of India. 12, 13

There were 17 questions to assess the knowledge and eight questions to assess the attitude/practice towards HPV infection. The knowledge was further assessed by scoring “one” for each correct response and was further analyzed. The knowledge scores less than 50% were considered “poor”, 50-75% as “moderate” and ≥76% as “good”. The urban and rural groups were further compared based on their knowledge and attitude toward HPV infection and its vaccination.

Results

A total of 271 female students were included in the study. Twenty-seven (10%) study participants belonged to 1^st pre-university while 244 (90%) belonged to 2^nd pre-university year. Two-hundred-and-fifty-eight (95%) of the study population was 16 to 17 years of age. The study group included 160 (59%) urban students and 111 (41%) rural students. One-hundred-and-twenty-four (46%) students’ fathers were educated up to high school or lower while 136 (50%) mothers were educated up to high school or lower (Table 1). One hundred and twelve (41%) fathers belonged to clerical/shop/farm work group while only 20 (7%) were unskilled workers. One-hundred-and-thirty (48%) mothers’ of study participants belonged to semi- or professional jobs while 34% were unemployed. One-hundred-and-fifty-eight (58%) study participants belonged to the upper class (Table 2).

Two-hundred-and-forty-nine (92%) of the study participants were Hindus. Two-hundred-and-twenty-eight (84%) study participants were living with their parents. Eleven (4%) study participants had a family history of cancer. Two-hundred-and-sixty-one (96%) students were using sanitary napkins during menstruation while only 10 (4%) were using cloth during menstruation. Three (1%) had a history of pre-marital sex (Table 3).

Internet (14%) was the commonest source of information about HPV followed by newspapers (13%). The other sources of information included doctors (10%), television (7%), text book (7%), friends (6%), parents (4%), and radio (2%). A total of 169 (62%) students were aware of the effects of HPV while only 12% were aware of the mode of HPV transmission. Only 16% of the study participants were aware of the symptoms of HPV infection and only 34% of the study participants were aware of HPV vaccination (Table 4). A total of 144 (53%) study participants were willing to take HPV vaccination if provided but 1/3^rd of them backed out after knowing the cost of vaccination (Table 5). The mean knowledge score was 5.6/17. Overall 224 (83%) study participants had poor knowledge about HPV infection (Table 6).

There was no age difference between the urban and the rural groups. The parents of the urban group were more educated than those of the rural group (Table 1). Most of the parents of the urban population were either professionals or semi-professionals while most of the parents of the rural population were clerical, shop, or farm workers (Table 2). The families in the urban group belonged to higher socio-economic status than those in the rural group (Table 2). There was no difference in family history, menstrual hygiene, or religion between the urban and rural groups (Table 3). The study participants from the urban area had more knowledge about the effects of HPV (118/160 vs. 51/111; p <0.0001) than those from the rural area but there was no difference between them regarding the knowledge of the mode of transmission of HPV. The urban group had more knowledge about the symptoms of HPV infection (32/160 vs. 11/111; p=0.009), the availability of HPV vaccine (66/160 vs. 25/111; p=0.001), and the ideal age group for HPV vaccination (90/160 vs. 33/111; p <0.0001) compared to the rural group (Table 4). There was no difference between the urban and the rural group in terms of attitude and practice toward HPV infection and its vaccination (Table 5). The overall knowledge score was better in the urban group compared to the rural group (Table 6).

Discussion

Cervical cancer is one of the leading causes of cancer-related deaths in women globally with more than a quarter occurring in developing countries. 15 One in 53 Indian women are prone to develop cervical cancer in their lifetime. 15 HPV is responsible for 99% of cervical cancers and is also responsible for anal cancer, genital warts, and other genital diseases. 3, 4, 16 Early age at first sexual intercourse, early age at marriage, early age at first full-term pregnancy, long-term use of hormonal contraceptives, and multiple pregnancies are responsible for the progression of HPV infection to neoplastic cervical lesions in India. 10 These neoplastic lesions and the presence of high-risk HPV strains in India are responsible for the increased incidence of cervical malignancy in India. 10

Amongst the 170 strains of HPV, 40 strains are transmitted sexually. 17 A few reports predict that more than 75% of sexually active individuals will be infected with HPV in their lifetime. 17, 18 HPV types 6 and 11 are associated with 90% of genital warts while types 16 and 18 are associated with a majority of cervical and anal malignancy. 10

There are three vaccines available against HPV, namely, Gardasil, Gardasil 9, and Cervarix. All three vaccines are safe and more than 90% effective.19, 20 Because of the poor response from the at-risk individuals, the vaccine didn’t produce its potential health impact in India. 10 The possible reasons were the cost of the vaccine, misinformation about the HPV vaccine, limited knowledge, acceptance, socio-demographic factors, cultural belief, and lack of awareness.9 This led to the suspension of HPV vaccination in India but sooner reapproved based on the effect of the vaccine in developed countries. 10 At present, the Indian Academy of Pediatrics recommends HPV vaccination with 2 doses at 0 and 6 months to girls between 9 and 14 years; and three doses at 0, 1, and 6 months to girls above 15 years.21

The study evaluated the knowledge of HPV & HPV Vaccination in at-risk population and their attitude/practice in Tumkur district, Karnataka state, India. Around 62% of the study population was aware of the effects of HPV but only 34% were aware of HPV vaccination. Only 14% were aware of the symptoms of HPV. The overall knowledge score was only 5.6/17. The studies in various developing countries showed similar results. A study by Liu Y et al found that the at-risk population had low-moderate knowledge (3.78/8) about HPV and its vaccination.16 Similar findings were noted in other countries such as Khan TM et al in Pakistan and Dany M et al in Lebanon who found that 57% and 37% of knowledge in the at-risk population. 22, 23 Even in Singapore, the students’ median knowledge score was only 7/14. 24

The Internet followed by newspapers was the most common source of information in our study population. The poor knowledge of these at-risk population can be increased by the government by promoting the HPV vaccination on social media and in newspapers. Health education plays an important role in promoting vaccination, especially by doctors or health authorities. Hence, schools and colleges should organize health education sessions in coordination with the health department to promote HPV vaccination. Government can also promote vaccination by including health education in textbooks.

Around 53% of our study population showed interest in HPV vaccination but 1/3^rd of them backed out after knowing the cost of vaccination. So, the government should include HPV vaccination under National Immunization Programme.

The urban group fared better than the rural population in knowledge about HPV. The urban group was also found to be more educated and belonged to a higher socioeconomic status which would have helped them know more about HPV. This is similar to other studies such as Hussain S et al. 25 A study by Degarege et al found that the knowledge about HPV and its vaccine was higher amongst the parents of urban areas compared to rural areas. 10 This could be because of a higher rate of formal education in urban areas compared to rural areas. 26 Also, the higher literacy rates, the presence of more healthcare facilities, radio, television, and internet are also responsible for higher knowledge in urban areas compared to rural areas. 26 But the attitude and practices were found to be the same in both urban and rural groups.

Increasing the awareness and knowledge about HPV infection and vaccination against it will promote the acceptability of HPV vaccination in at-risk population and their parents.27 So, promoting health education about HPV infection and including HPV vaccination in the national immunization schedule will help reduce the incidence of HPV infection and cervical cancer. Some states in India such as Delhi and Punjab have already included HPV vaccination in their state immunization programme. 28, 29

Conclusion

The study population was found to have poor knowledge about HPV infection and HPV vaccination. Only 53% of study participants were willing to take HPV vaccination if provided but 1/3^rd of them backed out after knowing the cost of vaccination. The overall knowledge score was better in the urban group compared to the rural group but there was no difference between them regarding attitude and practice toward HPV infection and its vaccination.

Author Contributions

Conceptualization: RHK, SR, VR. Data curation: RHK, SR. Formal analysis: SR, VR. Funding acquisition: None. Methodology: RHK, SR, VR. Project ad­ministration: RHK, SR, VR. Visualization: RHK, SR, VR. Writing - original draft: VR. Writing - review & editing: RHK, SR.

Source of Funding

None.

Conflict of Interest

None.