Abstract
Objective:
The purpose of this study was to examine factors predicting HPV vaccine acceptability among parents of adolescent girls in a rural area in Mysore district, India.
Design:
Cross sectional
Setting:
Mysore, India
Participants:
Parents of school going adolescent girls
Intervention:
Parents completed a validated self-administered questionnaire
Main outcome measures:
Parental willingness to vaccinate their daughters with HPV vaccine
Results:
Of the 831 parents participated in this study, 79.9% were willing to vaccinate their daughter with HPV vaccine sometime soon if they were invited to receive it. Higher odds of parental willingness to vaccinate their daughters with HPV vaccine was observed among those who believed that HPV vaccine is safe (Adjusted Odds Ratio [aOR] 2.11;95% CI:1.01, 4.45); daughter may become sexually active (aOR1.84, 95%CI:1.08, 3.13); they have support of other family members to vaccinate their daughter (aOR2.86,95%CI:1.47,5.57); HPV infection causes severe health problems(aOR1.64,95%CI:1.04,2.57). On the other hand, parents who believed that there is low risk that daughter will get cervical cancer(aOR0.52,95%CI:0.29,0.95); family will disapprove of getting daughter vaccinated(aOR0.45,95%CI:0.22,0.76); the injection may cause pain(aOR0.53, 95%CI:0.31,0.89) and were older age parents (aOR0.96,95%CI:0.93,0.99) had lower odds of willingness to vaccinate daughters with HPV vaccine.
Conclusions:
Acceptance of HPV vaccination for daughters was high among rural parents in Mysore, India. However, health education to reduce the belief that injection is painful and daughters are at low risk to get cervical cancer is important to further improve parental HPV vaccine acceptability in Mysore. The public health education should target older aged parents and extended family members.
Keywords: HPV, vaccine, acceptability, India, Mysore, Parents, Rural
Introduction
Cervical cancer is the second leading cause of cancer death among women in India.1 Every year, about 122,844 women are diagnosed with the disease and 67,477 die from it.1 The country ranked first in terms of the incidence of the disease among south Asian countries in 2012.2 In order to effectively control cervical cancer, the Indian Academy of Pediatrics Committee on Immunization(IAPCOI) approved HPV vaccination for females aged 10-12 years, who can afford the vaccine, in 2008.3 Nevertheless, introducing HPV vaccine in India has had unique challenges due to unconfirmed concerns about the efficacy and safety of the vaccine.4 The death of seven girls reported during demonstration program in India conducted in 2009 raised several concerns.4 The Indian parliament attributed the deaths to the HPV vaccine leading to suspension of the demonstration program in 2010.5 However, subsequent studies and investigations confirmed that the deaths were not related to the HPV vaccine.6
In 2014, the Government of India decided to include HPV vaccine in the National Immunization Programme.7,8 The vaccine, currently, is used by private practitioners in different regions of the country.6, 9,10 However, uptake of HPV vaccination in general has been low due to misperceptions about HPV infection, cervical cancer and HPV vaccine, and due to cultural reasons in India.7,11-14 Further investigation of factors that are related to HPV vaccine acceptability among parents in India may help improve uptake and reduce the burden of cervical cancer in this country. Identifying factors associated with vaccine acceptance will also help clinicians and public health advocates to better design evidence-based strategies to achieve maximum HPV vaccine coverage in the target groups. Much of the research to date about HPV vaccine acceptability in India has been limited to urban areas with very limited information being available from rural India where 60% of the Indian population resides.11-14 The purpose of this study was therefore to examine factors predicting HPV vaccine acceptability among parents of adolescent girls in rural India in the south Indian state of Karnataka.
Methods
Study setting
Between September and October, 2011, a cross-sectional survey was conducted among parents of adolescent girls living in villages of Mysore Taluk, in the Indian state of Karnataka. Karnataka ranks 9th in terms of population (61 million) with the majority of residents living in rural areas.15 The age-standardized cervical cancer mortality rate in Karnataka was 16.5 per 100,000 in 2010.16
Ethical consideration
This study was conducted after review and approval by the Institutional Review Boards at Florida International University and Public Health Research Institute of India. In addition, permission to conduct the study was obtained from the Block Education officer and school administrators. Parents participated in the study after they provided written informed consent.
Study participants
A total of 831 parents of adolescent girls (ages 11 to 15 years) attending 7th through 10th grades in a cluster of 11 schools located in rural Mysore sub-district were included in this study. One private and ten government schools were selected from a group of 43 schools available in the study area based on probability proportionate-to-size sampling. A program announcement was sent home with all eligible girls (n= 1,725) in the 11 schools (44 to 137 students from each school), explaining the objective of the study and inviting parents to participate. Of the 1725, 850 were randomly selected and provided a questionnaire in Kannada to complete within a week’s time. The number of female students needed from each school was determined based on multistage proportionate-to-size sampling. All (along with assigned number) eligible female students from each school were enumerated and listed in an excel sheet separately for each school. Using a computer program, the assigned number of students from each school were selected using a random sampling technique. Each selected and interested participant was provided with a questionnaire to take home to their parents, where one parent per household could complete it and return within seven days along with a signed consent form. Most parents (97.8%) who received the questionnaire completed the questionnaire and returned it along with their signed consent form.
Questionnaire and measures
The items included in the questionnaire were adapted from previous studies.11,17,18 The questionnaire was validated in Kannada (local language in the study area) and has been used in another study14 before it was used in this study. As some of the parents living in a rural region were illiterate and may have lacked knowledge about HPV, cervical cancer and HPV vaccine, we included some basic information in the questionnaire (Figure 1) to enable parents to answer some questions related to attitudes and beliefs about HPV vaccine and willingness to accept HPV vaccination. The questionnaire contained 126 items, 59 of which were used to measure psychosocial factors that have been shown to influence HPV vaccine acceptability in different countries including India.
Fig 1:
HPV, cervical cancer and HPV vaccine information presented to the participants in Mysore, India, 2011
The current study was guided by the conceptual framework of factors that influence HPV vaccination proposed by Fernandez et al.19 Out of 126 items, 59 items representing different constructs that could potentially influence willingness to vaccinate were selected for the analysis.19 The constructs included sociodemographics, awareness about HPV, sources of information about HPV vaccine, perceived susceptibility to HPV and cervical cancer, perceived severity of HPV and cervical cancer, perceived facilitators and barriers to vaccination in general and specific to HPV vaccine, social norms that influence HPV vaccine acceptability, and willingness to accept HPV vaccine.19
Awareness about HPV was assessed by one question (Have you ever heard of HPV?) with a ‘yes’ or ‘no’ response. Sources of information was assessed using seven items asking parents where they got information about HPV vaccine (Cronbach’s alpha [α]= 0.75). Perceived susceptibility, which measures parental attitudes towards susceptibility of their daughters to getting HPV infection and cervical cancer, was assessed using four items (α= 0.78). Similarly, perceived severity measured parental beliefs about severity of HPV infection and cervical cancer using four items (α= 0.73). Response to all the items that measured perceived susceptibility and severity constructs were recorded on a three-point scale (1=disagree, 2=do not know, 3=agree). Items that has a response of ‘Don’t know’ were assumed to be ordinally neutral.20
Questions used to assess parental beliefs and attitudes about HPV vaccine were grouped into two constructs: perceived facilitators/benefits and perceived barriers to HPV vaccination. Perceived facilitators were measured using eight items to assess the reasons why parents wanted to have their daughter’s HPV vaccination (α=0.67). Similarly, perceived barriers to HPV vaccination construct was measured using eight items to assess reasons why parents might not want to have their daughters receive HPV vaccine (α=0.68). Responses to the 16 items were coded on a three-point scale (1= not important all, 2=important 3=very important). Likewise, perceived facilitators (α=0.59) and perceived barriers (α=0.58) to vaccination in general were assessed using six and five items, respectively. These 11 items were recorded on a three-point scale (1=no, 2=not sure, 3=yes). Social norms were assessed using seven items (α=0.75) by asking parents whose opinion such as doctors, spouse, friends, father and mother, other relatives, in-laws and neighbors might influence their decision in getting their daughter vaccinated. Responses were recorded on three-point scale (1=no, 2=don’t know, 3=yes). Finally, the construct for willingness to accept HPV vaccine was assessed by asking parents ‘If your daughter was invited to get HPV vaccine, would you agree to have it sometime soon’. Responses were coded on a four-point Likert scale (1= definitely not, 2= probably not, 3= probably yes, 4= definitely yes). This variable was converted into a dichotomous variable as acceptors (who responded as ‘probably or definitely’ yes) and non-acceptors (who responded as ‘probably or definitely’ not) during data analysis.18
Data analysis
Data were analyzed using STATA software (Version 14, Texas, USA). Reliability/internal consistency of items forming each construct, was assessed using Cronbach’s alpha. The outcome variable was ‘HPV vaccine acceptability’. The calculated internal reliabilities (Cronbach’s α) for the items forming the constructs were substantial or moderate. Thus, a composite score was developed by adding values of responses to the items that form each of the construct.19
Percentages were used to describe the demographic status and the frequency of responses of parents to the questions addressing willingness to receive HPV vaccine, as well as beliefs and attitudes about HPV infection, cervical cancer and HPV vaccine. Chi-square tests were performed to check whether parental intention to accept HPV vaccine for their daughter was related to demographic characteristics, as well as beliefs and attitudes of parents about HPV, cervical cancer, and HPV vaccine. Multiple logistic regression was used to assess factors associated with HPV vaccine acceptance. To account for potential clustering of HPV acceptance by the school that the daughters attended, analysis was performed using the Generalized Estimating Equations (GEE) in Stata using the xtgee command. Estimated within-school correlation matrix value for HPV vaccine acceptability was 0.0078. While fitting the regression models, factors that were included in the regression model were checked for multicollinearity. As there were missing values for some of the items (Missing range: 0.48 to 3.61%) included in the regression model, a multiple imputation method (using chained equation) based on 20 iterations was used to estimate the missing values before fitting the GEE.21
Results
Of the 850 parents who were contacted, 831 agreed to participate and returned the completed questionnaire within seven days. The mean age of the parents was 37.1± 6.67 years. Almost all study participants were Hindu by religion (99.0%) and married (91.5%). Most respondents were mothers (76.8%), working part-time (43.0%) and lacked formal education (63.4%). Most had heard about HPV (75.4%). Majority of the parents got information about HPV vaccines from their daughter's school (86.6%), doctor (83.6%), television (76.2%), Auxillary Nurse Midwife or anganwadi teacher (72.0%). Of the 831 parents, 79.9% (Yes probably=30.2%, Yes definitely=49.7%) were willing to vaccinate their daughter with HPV vaccine sometime soon if they were offered the vaccine for their daughter (Table 1). When compared to mothers, fathers were more likely to be educated (55.4% vs 30.9%), employed (92.2% vs 46.2%), and older than 35 years of age (87.6% vs 34.3%). However, the proportion of parents who were Hindus, married, and were willing to vaccinate their daughter with HPV vaccine were similar between fathers (99.5%, 94.3% and 77.7%, respectively) and mothers (98.9%, 90.6% and 80.6%, respectively).
Table 1.
Sociodemographic characteristics of participants and HPV vaccine acceptability in Mysore, India, 2011 (N=831)
| Total | Percent of willing to vaccinate |
p-value | ||
|---|---|---|---|---|
| Sex | Male | 193 | 77.7 | |
| Female | 638 | 80.6 | 0.388 | |
| Age in years | ≤35 | 443 | 81.5 | 0.125 |
| 36-40 | 228 | 80.3 | ||
| 41-50 | 129 | 77.5 | ||
| >50 | 31 | 64.5 | ||
| Education | No formal education | 527 | 76.1 | 0.006 |
| Grade 1 to 10th | 285 | 86.3 | ||
| More than 10th grade | 19 | 89.5 | ||
| Occupation | Retired/unemployed | 11 | 72.7 | 0.030 |
| Full-time homemaker | 347 | 82.1 | ||
| Self-employed | 58 | 87.9 | ||
| Employed part-time | 357 | 75.4 | ||
| Employed full-time | 58 | 87.9 | ||
| Marital Status | Separated/widowed | 71 | 78.9 | 0.821 |
| Married | 760 | 80.0 | ||
| Religion | Hindus | 823 | 80.0 | 0.728 |
| Muslim | 8 | 75.0 | ||
| Have you ever heard about HPV? | No | 204 | 83.3 | 0.159 |
| Yes | 627 | 78.8 |
Parents who were willing to vaccinate their daughter with HPV vaccine reported the following characters as main reasons for their willingness: recommendation from doctor or nurse (96.2%), belief that HPV vaccine will prevent cervical cancer (92.8%), belief that HPV vaccine is safe (92.0%), having support from other family members to vaccinate daughter with HPV vaccine (89.5%), and learning more about the relationship of HPV to cervical cancer (89.2%) (Table 2).
Table 2.
Attitudes and beliefs about HPV, cervical cancer and vaccination and HPV vaccine acceptability in Mysore, India, 2011 (N=831)
| Total | Percent willing to vaccinate |
p-value | ||
|---|---|---|---|---|
| Susceptibility to HPV or cervical cancer | ||||
| My daughter may be at risk of getting HPV infection | Disagree | 194 | 76.8 | 0.419 |
| Do not know | 523 | 80.5 | ||
| Agree | 114 | 82.5 | ||
| It is likely that my daughter may get HPV infection in the future | Disagree | 172 | 77.3 | 0.168 |
| Do not know | 538 | 79.4 | ||
| Agree | 121 | 86.0 | ||
| It is possible that my daughter will get cervical cancer in the future | Disagree | 175 | 76.6 | 0.290 |
| Do not know | 555 | 81.4 | ||
| Agree | 101 | 77.2 | ||
| It is likely that my daughter may get cervical cancer someday | Disagree | 184 | 77.2 | 0.532 |
| Do not know | 531 | 81.0 | ||
| Agree | 116 | 79.3 | ||
| Severity of HPV or cervical cancer | ||||
| I believe that HPV infection can cause serious health problem | Disagree | 74 | 70.3 | <0.001 |
| Do not know | 283 | 73.1 | ||
| Agree | 474 | 85.4 | ||
| I believe that HPV infection can be extremely harmful. | Disagree | 84 | 64.3 | <0.001 |
| Do not know | 226 | 71.2 | ||
| Agree | 521 | 86.2 | ||
| I believe that cervical cancer is a serious disease | Disagree | 90 | 68.9 | <0.001 |
| Do not know | 245 | 73.9 | ||
| Agree | 496 | 84.9 | ||
| I believe that cervical cancer can be extremely harmful. | Disagree | 73 | 65.8 | <0.001 |
| Do not know | 523 | 84.7 | ||
| Agree | 235 | 73.6 | ||
| Perceived facilitators to HPV vaccination | ||||
| Recommendation from doctor or nurse | No | 40 | 57.5 | |
| Yes | 787 | 81.2 | <0.001 | |
| Worry about daughter getting cervical cancer | No | 346 | 77.5 | |
| Yes | 470 | 81.3 | 0.180 | |
| Believe that HPV vaccine is safe | No | 68 | 54.4 | |
| Yes | 740 | 82.6 | <0.001 | |
| Worry that daughter may become sexually active | No | 379 | 76.0 | |
| Yes | 403 | 83.4 | 0.01 | |
| Support from family members to vaccinate your daughter | No | 107 | 59.8 | |
| Yes | 716 | 82.9 | <0.001 | |
| Knowing more about the relationship of HPV to cervical cancer | No | 103 | 64.1 | |
| Yes | 722 | 82.0 | <0.001 | |
| Government approval of vaccine | No | 117 | 67.5 | |
| Yes | 698 | 81.8 | <0.001 | |
| Belief that vaccine will prevent cervical cancer | No | 77 | 57.1 | |
| Yes | 748 | 82.3 | <0.001 | |
| Perceived facilitators to vaccination in general | ||||
| Vaccinations are effective in preventing disease | No | 123 | 72.4 | |
| Not sure | 168 | 78.6 | ||
| Yes | 515 | 82.5 | 0.034 | |
| It is very important that my daughter receive all her vaccinations | No | 15 | 53.3 | |
| Not sure | 42 | 66.7 | 0.002 | |
| Yes | 767 | 81.4 | ||
| Vaccination is one way that parents can ensure their child health | No | 23 | 39.1 | |
| Not sure | 64 | 59.4 | ||
| Yes | 732 | 83.5 | <0.001 | |
| I have a responsibility to have my children vaccinated for the protection of all children. | No | 17 | 76.5 | |
| Not sure | 27 | 55.6 | 0.004 | |
| Yes | 770 | 81.2 | ||
| The government does a good job providing vaccine and health services | No | 33 | 84.8 | |
| Not sure | 75 | 68.0 | 0.016 | |
| Yes | 708 | 81.5 | ||
| I would feel responsible if anything bad happened I did not my child vaccinated | No | 105 | 76.2 | |
| Not sure | 97 | 71.1 | ||
| Yes | 600 | 83.7 | <0.005 | |
| Perceived barriers to HPV vaccination | ||||
| High cost of the vaccine | No | 281 | 75.8 | |
| Yes | 544 | 81.8 | 0.042 | |
| Low risk that daughter will be infected with HPV | No | 230 | 75.2 | |
| Yes | 590 | 81.4 | 0.050 | |
| Low risk that daughter will get cervical cancer | No | 255 | 78.8 | |
| Yes | 562 | 80.3 | 0.638 | |
| Family will disapproval of getting daughter vaccinated | No | 383 | 83.0 | |
| Yes | 430 | 77.4 | 0.047 | |
| Injection may cause pain | No | 360 | 85.0 | |
| Yes | 459 | 76.0 | 0.001 | |
| Not enough information available about HPV vaccine | No | 253 | 75.1 | |
| Yes | 563 | 82.2 | 0.018 | |
| Worried about safety of the vaccine | No | 228 | 77.1 | |
| Yes | 591 | 81.0 | 0.131 | |
| Vaccination may not be effective | No | 257 | 78.6 | |
| Yes | 569 | 80.3 | 0.569 | |
| Perceived barriers to vaccination in general | ||||
| I would feel responsible if anything bad happened I had my child vaccinated | No | 226 | 77.9 | |
| Not sure | 133 | 84.2 | 0.278 | |
| Yes | 442 | 81.9 | ||
| I am concerned about side effects of vaccinations | No | 314 | 79.9 | |
| Not sure | 189 | 80.4 | 0.811 | |
| Yes | 299 | 81.9 | ||
| I am afraid of vaccinating my children | No | 521 | 83.7 | |
| Not sure | 63 | 57.1 | <0.001 | |
| Yes | 238 | 78.2 | ||
| It is better to get the disease and get protected naturally than vaccinated | No | 158 | 87.3 | |
| Not sure | 92 | 75.0 | 0.027 | |
| Yes | 563 | 78.9 | ||
| There are too many vaccines already included in childhood vaccine schedule | No | 83 | 59.0 | |
| Not sure | 180 | 80.6 | <0.001 | |
| Yes | 556 | 82.9 | ||
Numbers for some items do not add up to 831 due to missing data
Among parents who refused to vaccinate their daughter with HPV vaccine, the most frequent reasons for refusal were, being worried about safety of the vaccine (67.1%), the perception that the vaccination may not be effective (67.1%), that injection may cause pain (65.9%) and their perception that their daughter is at low risk of becoming infected with HPV infection (65.9%). Willingness to receive HPV vaccine was also lower among parents who were afraid of vaccinations in general.
Based on multiple regression analysis, the odds ratio of willingness to vaccinate was positively associated with the perceived benefits of HPV vaccination (aOR 1.16, 95%CI: 1.07, 1.25). The odds ratio of willingness to vaccinate was particularly greater among parents who believed that the vaccine was safe (aOR 2.11; 95%CI: 1.01, 4.45); daughter may become sexually active (aOR 1.84, 95%CI: 1.08, 3.13); and they have support from other family members to vaccinate their daughter (aOR 2.86, 95%CI: 1.47, 5.57). Willingness to vaccinate their daughter with HPV vaccination was also greater among parents who believed that vaccination was one way that parents could ensure their child’s health (aOR 10.75, 95%CI: 3.04, 38.0), and among those who believed that HPV infection could cause severe health problems (aOR 1.64, 95%CI: 1.04, 2.57). Parents with 1 to 10 years of education were more willing to vaccinate their daughter as compared to parents who lacked any education (1.92, 95%CI: 1.13, 3.26) (Table 3).
Table 3.
Facilitators and barriers to accept HPV vaccination among 831 rural parents in Mysore in Mysore, India, 2011
| Variables | Categories | Unadjusted OR (95% CI) |
Adjusted OR (95% CI) |
|---|---|---|---|
| Sociodemographic factors | |||
| Sex | Female | 1.17 (0.78, 1.73) | 1.11 (0.59, 2.10) |
| Age | Continuous | 0.98 (0.95, 1.00) | 0.96 (0.93, 0.99) |
| Education | Grade1 to 10th | 1.95 (1.32, 2.90) | 1.92 (1.13, 3.26) |
| ≥High school | 2.59 (0.59, 11.26) | 2.09 (0.36, 12.11) | |
| Occupation | Employed | 0.81 (0.57, 1.15) | 1.17 (0.71, 1.92) |
| Marital Status | Married | 1.05 (0.58, 1.92) | 0.48 (0.21, 1.11) |
| Religion | Muslims | 0.71 (0.14, 3.47) | 0.68 (.09, 5.02) |
| Awareness about HPV (Have you ever heard about HPV?) | Yes | 1.33 (0.88, 2.03) | 1.22 (0.70, 2.10) |
| Susceptibility to HPV and cervical cancer | Continuous | 1.06 (0.97, 1.16)* | 0.99 (0.89, 1.10)* |
| HPV | Continuous | 1.33 (0.95, 1.85) | 1.50 (.86, 2.61) |
| Cervical cancer | Continuous | 1.08 (0.77, 1.51) | 0.90 (0.52, 1.56) |
| Severity of HPV and cervical cancer | Continuous | 1.31 (1.20, 1.42)* | 1.21 (1.10, 1.33)* |
| HPV | Continuous | 2.42 (1.80, 3.24) | 1.64 (1.04, 2.57) |
| Cervical cancer | Continuous | 2.09 (1.58, 2.77 ) | 1.16 (0.73, 1.83) |
| Perceived facilitators to HPV vaccination | Continuous | 1.17 (1.10, 1.24)* | 1.16 (1.07, 1.25)* |
| Recommendation from doctor or nurse | Yes | 3.20 (1.67, 6.14) | 1.07 (0.41, 2.79) |
| Worry about daughter getting cervical cancer | Yes | 1.23 (0.88, 1.74 ) | 0.82 (0.48, 1.39) |
| Belief that HPV vaccine is safe | Yes | 3.96 (2.37, 6.63) | 2.11 (1.01, 4.45) |
| Worry that daughter may become sexually active | Yes | 1.27 (1.01, 1.59) | 1.84 (1.08, 3.13) |
| Support from family members to vaccinate your daughter | Yes | 3.21 (2.08, 4.95 ) | 2.86 (1.47, 5.57) |
| Knowing about the relationship of HPV to cervical cancer | Yes | 2.54 (1.62, 3.96) | 0.92 (0.44, 1.95) |
| Government approval of vaccine | Yes | 2.23 (1.44, 3.44) | 0.94 (0.49, 1.80) |
| Belief that vaccine will prevent cervical cancer | Yes | 3.49 (2.14, 5.69) | 1.57 (0.73, 3.36) |
| Perceived facilitators to vaccination in general | Continuous | 1.26 (1.13,1.40)* | 1.09 (0.95, 1.25)* |
| Vaccinations are effective in preventing disease | Ye | 1.85 (1.17, 2.93) | 1.01 (0.51, 2.00) |
| It is very important that my daughter receive all her vaccinations | Yes | 4.00 (1.43, 11.20 ) | 1.63 (0.28, 9.35) |
| Vaccination is one way that parents can ensure their child health | Yes | 7.56 (3.22, 17.74) | 10.75 (3.04, 38.0) |
| I have a responsibility to have my children vaccinated for the protection of all children | Yes | 1.76 (0.62, 4.98) | 0.33 (0.05, 2.08) |
| The government does a good job providing vaccine and health services | Yes | 0.88 (0.33, 2.39) | 0.31 (0.07, 1.32) |
| I would feel responsible if anything bad happened I did not have my child vaccinated | Yes | 1.67 (1.02, 2.75 ) | 1.04 (0.50, 2.15) |
| Perceived barriers to HPV vaccination | Continuous | 0.99 (0.95, 1.04)* | 0.92 (0.87, 0.99)* |
| High cost of the vaccine | Yes | 1.40 (0.98, 1.98) | 1.77 (1.06, 2.96) |
| Low risk that daughter will be infected with HPV | Yes | 1.43 (0.99, 2.07) | 1.17 (0.64, 2.14) |
| Low risk that daughter will get cervical cancer | Yes | 1.07 (0.74, 1.53) | 0.52 (0.29, 0.95) |
| Family will disapproval of getting daughter vaccinated | Yes | 0.68 (0.48, 0 .97) | 0.45 (0.26, 0.76) |
| Injection may cause pain | Yes | 0.57 (0.40, 0.82) | 0.53 (0.31, 0.89) |
| Not enough information available about HPV vaccine | Yes | 1.51 (1.05, 2.16) | 1.86 (1.09, 3.18) |
| Worried about safety of the vaccine | Yes | 1.29 (0.89, 1.86) | 0.87 (0.49, 1.54) |
| Vaccination may not be effective | Yes | 0.91 (0.63, 1.31) | 1.00 (0.57, 1.77) |
| Perceived barriers to vaccination in general | Continuous | 0.97 (0.89, 1.07)* | 0.99 (0.89, 1.10)* |
| I would feel responsible if anything bad happened I had my child vaccinated | Yes | 1.27 (0.85, 1.88 ) | 1.05 (0.58, 1.89) |
| I am concerned about side effects of vaccinations | Yes | 1.09 (0.72, 1.66) | 0.95 (0.55, 1.66) |
| I am afraid of vaccinating my children | Yes | 0.68 (0.46, 1.01) | 0.77 (0.44, 1.35) |
| It is better to get the disease and get protected naturally than vaccinated | Yes | 0.56 (0.33, 0.93) | 1.05 (0.54, 2.04) |
| There are too many vaccines already included in childhood vaccine schedule | Yes | 3.37 (2.06, 5.49) | 1.90 (0.94, 3.84) |
| Do you know someone with cervical cancer? | Yes | 0.65 (0.36, 1.15) | 0.61 (0.27, 1.38) |
| Social norms | Continuous | 1.03 (0.99, 1.07)* | 1.01 (0.97, 1.04)* |
| Do you think the following people would want you to vaccinate your daughter against HPV infection | |||
| Your Doctors | Yes | 1.94(1.23, 3.07) | 1.55 (0.83, 2.92) |
| Your spouse | Yes | 2.14 (1.42, 3.24) | 2.25 (1.22, 4.12 ) |
| Your friends | Yes | 1.19 (0.77, 1.83) | 1.06 (0.53, 2.09) |
| Your father & mother | Yes | 1.77 (1.14, 2.74) | 0.84 (0.44, 1.64) |
| Other relatives | Yes | 0.72 (0.48, 1.10) | 0.44 (0.20, 0.94) |
| Your in-laws | Yes | 1.33 (0.89, 1.98) | 1.48 (0.76, 2.88) |
| Your neighbors | Yes | 0.87 (0.54, 1.40) | 0.78 (0.35, 1.74) |
| Source of information about HPV vaccine | Continuous | 1.09 (1.00, 1.18)* | 1.05 (0.95, 1.16)* |
| Television | Yes | 1.96 (1.32, 2.92) | 1.16 (0.57, 2.38 ) |
| Newspaper or Radio | Yes | 1.26 (0.86, 1.85) | 0.78 (0.41, 1.51) |
| Internet | Yes | 1.07 (0.76, 1.52) | 1.49 (0.89, 2.50) |
| Doctor | Yes | 2.07 (1.29, 3.30) | 1.50 (0.70, 3.19) |
| ANM or Anganwadi teacher or Worker | Yes | 1.14 (0.74, 1.77) | 0.53 (0.27, 1.03) |
| Friends or Neighbours | Yes | 1.20 (0.83, 1.73) | 0.71 (0.38, 1.31) |
| My daughter's school | Yes | 0.80 (0.38, 1.67) | 0.90 (0.35, 2.31) |
| Family member or relatives | Yes | 1.25 (0.87, 1.80) | 1.80 (0.94, 3.45 ) |
| Recommended age for HPV vaccination | Continuous | 1.13 (0.96, 1.35) | 1.10 (0.88, 1.38) |
Odds ratio estimates are based on a GEE that included constructs with composite scores estimated based on the sum of scores of individual items that formed the constructs.
Reference for ‘yes’ categories are ‘no’
On the other hand, the odds ratio of willingness to vaccinate was negatively associated with the perceived barriers of HPV vaccination (aOR 0.92, 95%CI: 0.87, 0.99). The odds were particularly lower among parents who believed that their daughter was at low risk to get cervical cancer (aOR 0.52, 95%CI: 0.29, 0.95); the family may disapprove of getting their daughter vaccinated (aOR 0.45, 95%CI: 0.22, 0.76) and the injection may cause pain (aOR 0.53, 95%CI: 0.31, 0.89). Parental willingness to vaccinate their daughter also decreased with increasing age of the parent (aOR 0.96, 95%CI: 0.93, 0.99) (table 3).
Discussion
The purpose of this study was to examine facilitators and barriers to parental acceptability of HPV vaccine for adolescent girls in rural Mysore, India. The majority of the parents (79.9%) were willing to vaccinate their daughter with HPV vaccine. The main factors associated with HPV vaccine acceptance were parental education, the belief that the vaccine was safe and HPV infection could cause severe health problems, daughter might become sexually active, having support of other family members to vaccinate daughter, and believing that vaccination is one way to ensure their child’s health. On the contrary, low risk perception that daughter will get cervical cancer, fear that other family members might disapprove of getting daughter vaccinated, injection may cause pain, and increasing age of the parent were all associated with not intending to accept HPV vaccination for their daughter.
There was a higher rate of HPV vaccine acceptance in this population as compared to that reported among parents in the other regions of India (Range: 46% to 74%) 13,14,22 and other countries in south Asia (Range: 26.5% to 84.0%).23-26 Even within the same district, vaccine acceptance in this rural study population was greater than among parents living in the urban region (71.1%).14 This increased rate of HPV vaccine acceptance in the current study could be due to better awareness about cervical cancer and HPV vaccine, or due to a more positive attitude towards vaccinations in general and the immunization programs run by the government. Indeed, a study reported higher levels of knowledge about general issues related to vaccination among parents who lived in rural than urban areas of the same district, where the current study was conducted.11 The level of awareness about HPV in Senegal was also greater among adolescents and parents who were living in rural area than the urban ones. 27 The National Rural Health Mission that was started in 2005 by the government of India to improve maternal child health outcomes in rural India has focused on improving immunization coverage at the village level in rural India. This initiative may have also helped increase knowledge, sensitize the rural residents about the importance of immunization in general and helped develop positive attitudes towards vaccination among rural parents in this area.
The perception that their daughters were at low risk to get cervical cancer, pain associated with injection, and disapproval by other family members for vaccinating daughters were significant predictors of low parental acceptability HPV vaccine for their daughters. A study among urban parents in the same district also reported association of the belief that injection may cause pain with a lower odds of HPV vaccine acceptance.14 Parental beliefs that daughter may be at low risk of getting cervical cancer could be due to lack of knowledge that HPV infection is a cause for cervical cancer.7 Disapproval of other family members to get daughter vaccinated may be due to lack of awareness that adolescents are susceptible to HPV infection.28 To reduce these barriers and promote HPV vaccination of girls in this area in the future, public health education programs for parents must focus on the transmission mechanisms of HPV infection, cancers caused by HPV infection (e.g. cervical cancer), and the fact that cervical cancer can be prevented by HPV vaccination.29-33 Scope of this education should be broadened to include extended family members as they have a large influence on parental decision making to recommend HPV vaccination for girls in the community.
Another barrier to HPV vaccine acceptability in this study was the older age of the parent. This finding is consistent with a previous report from Indonesia, which showed lower HPV vaccine acceptance among older age parents compared to the younger ones.34 A study in Thailand also showed lower acceptability of HPV vaccine for daughters among parents older than 45 years compared to those younger than 45.24 More positive attitudes among younger parents could be due to changing sexual norms, access to information as compared to older age parents who may be less interested in health information related to sexually transmitted infection. In addition, older age parents may have negative beliefs about HPV vaccine due to previous experiences with and beliefs about vaccinations in general (side effects). Further research should focus on understanding the information needs of older parents to improve HPV vaccine acceptability in rural India.
A strength of this study was the focus on rural population—a population that has not been studied adequately. In addition, this study included a relatively large probability sample based on weighted random sampling methods. Almost all of the study participants contacted participated in this study as the population was interested and so few groups or organizations are interested in getting the opinion and understanding the needs of rural residents in this region. However, the study was not without limitations. Only parents of school going adolescent girls were included in this study. This would limit generalizability of the findings to parents who do not have school going children within that age group. Furthermore, due to variations in social practices, culture, religion and economic composition, all of which may affect individual beliefs about HPV, cervical cancer and HPV vaccine, the current study findings may not be generalizable to parents in other regions of India. The fact that only eight parents were Muslims in the current study may also limit generalizability of the results to other religions since the majority of the sample belonged to Hindu religion. Most of the Muslims in Mysore districts are concentrated in urban areas with very small percent living in rural regions. However, Muslims form a sizable portion of the overall population in India.15 In addition, as the data were self-reported, some parents, especially the illiterate ones, may have received support from friends or extended family members while responding to some questions which may have caused information bias. Moreover, although provision of information about cervical cancer prevention methods, HPV and HPV vaccine enabled illiterate parents or those who lacked knowledge to answer some questions related to attitudes and beliefs about cervical cancer, HPV and HPV vaccine, this might have also overestimated the strength of association between HPV vaccine acceptability and attitudes about HPV, cervical cancer and HPV vaccine in this sample. Moreover, there were missing data for some questions, which might lead to a biased estimation of the observed association between parental beliefs and attitudes about HPV vaccine and cervical cancer with HPV vaccine acceptance. However, the multiple imputation method used to predict the missing values showed results that were comparable to those obtained with analysis with complete dataset after removing the missing values. There was a very minor difference in the magnitude of the odds ratio, standard errors and 95% CI estimates. The current study assessed parents willingness to vaccinate their daughter with HPV vaccine. Hence, we cannot be sure if parents would actually vaccinate their daughter if the vaccine were offered. According to the conceptual framework proposed by Fernandez which guided this study, the nature of the environment will further modify the influence of parent’s willingness to vaccinate daughter with HPV vaccine on the actual uptake of HPV vaccine.19 Finally, the study was conducted between September and October, 2011. There may have been changes in the beliefs and attitudes of parents regarding HPV infection, cervical cancer and HPV vaccine in the last seven years. This time delay in the conduct and the presentation of the study results may influence the nature of policy measures that can be designed to increase HPV vaccine acceptability among rural parents in Mysore, India.
Conclusions
In conclusion, this study is one of few studies that addresses public health issues among rural Indians. Willingness to vaccinate daughters with HPV vaccine was high among rural parents in Mysore district. However, public health education programs to reduce the false perception of low risk of getting cervical cancer, and fear of pain with injection will be important issues to focus among parents in Karnataka to reduce cervical cancer rates and further improve parental acceptability of HPV vaccine in the district. Health education programs should target older aged parents as well as extended family members to ensure increased vaccination uptake in the future in rural India.
Acknowledgements
The study was funded by Investigator Initiated Award from Merck & Co., Inc. (grant number: D43 TW010540). The funder had no role in the study design, data collection, analysis, interpretation and publication of the manuscript. AD is funded by Dissertation Year Fellowship, Florida International University. KK is a Global Health Equity Scholar funded by the Fogarty International Center at National Institute for Health. We would like to thank the study participants for taking time to complete the questionnaires. We would also like to acknowledge and thank the Block Development Officer for Mysore and the administrative staff of the schools for their assistance in conducting this study.
Funding: This study was funded by Investigator Initiated Award from Merck & Co. (Grant number D43 TW010540).
Footnotes
Conflict of interest
The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article.
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