Acceptance of the nonavalent human papillomavirus vaccine among medical students: A knowledge, attitudes and practices study

INTRODUCTION

Human papillomavirus (HPV) is a deoxyribonucleic acid (DNA) containing virus that causes warts, cancers, and a variety of other conditions.^[1] Despite protecting against the strains most commonly responsible for the harmful sequelae of HPV infection, these vaccines do not prevent infection from the other less common but not insignificant strains of HPV responsible for such sequelae. This led to the development of the newer nonvalent HPV vaccine, which affords protection against nine high-risk HPV strains.^[2] It is gender neutral and can be administered to individuals who are 18-25 years of age.^[3] We aim to study the knowledge, attitudes, and practices (KAP) among medical students regarding this newer nonavalent vaccine and the effect of a focused training module on the same.

MATERIAL AND METHODS

This study was performed at the Department of Obstetrics and Gynaecology in a tertiary referral teaching centre. We included all willing medical students as participants, and data were collected over a period of one year. All willing medical students were first administered a semi-objective questionnaire in English. They were then subjected to a 20-minute visual training presentation on HPV vaccination. The same semi-objective questionnaire was then readministered. The questionnaire contained 9 objective dichotomous questions and 5 questions pertaining to KAP. Data was collected from and training imparted to batches of around 15-20 students at a time. It is shown in Supplementary File 1. Data recorded were demographic details, year of study, performance on the objective questions, and KAP-related characteristics. The training material is shown in Supplementary File 2.

RESULTS

Study population and clinical characteristics

A total of 320 participants, with a mean (SD) age of 20.39 (1.648) years, were included in this study; 200 (62.5%) of them were female. 133 (41.6%) were first-year students, 67 (20.9%) were second-year students, 51 (15.9%) were third-year students and 69 (21.6%) were fourth-year students. Table 1 summarizes the characteristics of the study population and scores on the questionnaire.

Table 1: Summarising the characteristics of the study population

Variable	Category	Average [Count/Mean (Std.*)/%]		p value
		Pre training	Post training
Number	-	320	-	-
Age (years)	-	20.39 (1.648)	-	-
Sex(Females)	-	200 (62.5%)	-	-
Year	1st Year	133 (41.6%)	-	-
	2nd Year	67 (20.9%)	-	-
	3rd Year	51 (15.9%)	-	-
	4th Year	69 (21.6%)	-	-
Question 1	Correct	235 (73.4%)	307 (95.9%)	0.001
Question 2	Correct	86 (26.9%)	110 (34.4%)	0.016
Question 3	Correct	232 (72.5%)	289 (90.3%)	0.001
Question 4	Correct	195 (60.9%)	282 (88.1%)	0.001
Question 5	Correct	147 (45.9%)	282 (88.1%)	0.001
Question 6	Correct	110 (34.4%)	260 (81.3%)	0.001
Question 7	Correct	78 (24.4%)	228 (71.2%)	0.001
Question 8	Correct	258 (80.6%)	304 (95%)	0.001
Question 9	Correct	88 (27.5%)	237 (74.1%)	0.001
Objective Score		4.47 (1.5)	6.78 (1.308)	0.001
Improvement in score		2.32 (1.740)		-
Knowledge about gender neutral nonavalent vaccine	Present	44 (13.8%)	308 (96.3%)	0.001
Can 18-25 year old subjects be vaccinated?	Yes	29 (9.1%)	291 (90.9%)	0.001
Recommendation of nonavalent vaccine	Recommend	215 (67.2%)	281 (87.8%)	0.001
Reason for not recommending	Side effects	67 (63.7%)	6 (15.4%)	0.001
	Availability	12 (11.8%)	0
	Cost	5 (4.9%)	28 (71.8%)
	Others	20 (19.4%)	5 (12.8%)
Vaccination status	Vaccinated	29 (9.1%)

p<0.05 is statistically significant. Std: Standard deviation.

Supplementary File 1 contains the questionnaire, and Supplementary File 2 contains the training material. In question 1, pre-training 235(73.4%) participants answered correctly, which improved to 307 (95.9%) post-training, which was statistically significant, p = 0.001. Pre-training, 86 (26.9%) participants answered question 2 correctly, which improved to 110 (34.4%) post-training, which was statistically significant, p = 0.016. In question 3, pre-training 232 (72.5%) participants answered correctly, which improved to 289 (90.3%) post-training, which was statistically significant, p = 0.001. In question 4, pre-training 195(60.9%) participants answered correctly, which improved to 282(88.1%) post-training, which was statistically significant, p = 0.001. In question 5, pre-training 147 (45.9%) participants answered correctly, which improved to 282 (88.1%) post-training, which was statistically significant, p = 0.001. In question 6, pre-training 110 (34.4%) participants answered correctly, which improved to 260 (81.3%) post-training which was statistically significant, p = 0.001.

Supplementary File 2

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In question 7, pre training 78 (24.4%) participants answered correctly, which improved to 128 (38.8%) post-training which was statistically significant, p = 0.001.

In question 8, pre-training 258 (80.6%) participants answered correctly, which improved to 304 (95%) post-training, which was statistically significant, p = 0.001. In question 9, pre-training 88 (27.5%) participants answered correctly, which improved to 237 (74.1%) post-training, which was statistically significant, p = 0.001.Mean(SD) objective scores pre and post training were 4.47 (1.5) and 6.78 (1.308), respectively, showing significant improvement post training, p = 0.001. Male and female participants had similar improvement in objective questions post-training, whereas second-year students had significantly greater improvement compared to other years (p = 0.001), with first-year students having slightly greater but non-significant improvement compared to third and fourth years, who had similar improvement. Figure 1 shows improvement across year of study. 44 (13.8%) participants had knowledge about existence of the gender neutral nonavalent HPV vaccine pre training vs 308 (96.3%) participants post training with significant improvement, p = 0.00129 (9.1%) participants knew pre training that 18-25 year old subjects could be vaccinated with the gender neutral nonavalent HPV vaccine compared to 291(90.9%) post training, with significant improvement, p = 0.001.215 (67.2%) participants would recommend the nonavalent HPV vaccine pre training compared to 281 (87.8%) participants post training which improved significantly, p = 0.001.

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Figure 1: Box plot depicting post-training improvement in performance on objective questions according to year of study.

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Pre-training, potential side effects (67 participants [63.7%], and concerns regarding availability (12 participants [11.8%]) were the major reasons for not recommending the vaccine. Post-training, cost became the major reason for not recommending the vaccine (28 participants [71.8%]), followed by potential side effects (6 participants [15.4%]). Figure 2 depicts the reasons for not recommending the vaccine pre- and post-training. 29 (9.1%) participants were fully vaccinated with any HPV vaccine. There were no significant differences between genders and years of study.

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Figure 2: Pie charts depicting the reasons against the recommendation of the nonavalent HPV vaccine pre and post-training. HPV: Human papillomavirus.

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DISCUSSION

Human papillomavirus is the cause of many cancers, warts, and other sexually transmitted diseases. It is a cause of preventable morbidity and mortality in both men and women. Vaccines and screening programs have worked to reduce the serious sequelae of HPV infections in previous decades. HPV, due to having various viral types and differing surface antigens, may not be adequately covered if vaccines target only a few major types. A sizeable proportion of sequelae are caused by HPV viral types not presently targeted by the bivalent and quadrivalent vaccines. Hence, a novel nonavalent vaccine was developed, which targeted the majority of the common HPV viral types. It can be administered to 18-25 year olds as well.

Our study attempts to assess information and KAP that medical students have regarding the novel nonavalent HPV vaccine, along with evaluating the effectiveness of our training material in imparting and influencing the same. The questions in our semi-objective questionnaire assessed information pertaining to a variety of topics related to HPV and the vaccine, ranging from biological behaviour and transmission of HPV to the safety, efficacy, and indications of HPV vaccination [Supplementary File 1].

Questions 8 and 9 particularly pertain to the nonavalent HPV vaccine and, importantly, show significant improvement post-training. The improvement holds true even when analysed according to year of study, whereby students belonging to every year of study had a significant improvement in information. The baseline pre-training performance of the students was predictable, with older students belonging to advanced years of study outperforming younger students. Interestingly, as shown in Figure 1, the students belonging to the second year of medical study had significantly better improvement of performance on objective questions compared to students of other years of study, and their post-training performance on objective questions was much better, even compared to students belonging to advanced years of study. This may be explained by the fact that generally, students in the second year of their medical education are actively involved in learning about the immunology, virology, and microbiology of HPV and HPV vaccination, which may reflect in better uptake of the training material and thus, improvement in objective knowledge. There was no significant gender difference in performance on objective questions, KAP, or vaccination status; thus, with lower gender disparity, medical students as a population are predictably better informed than the general population.

Figure 2 shows the change in KAP pertaining to recommending the newer nonavalent HPV vaccine, where not only has the overall mindset about recommending the vaccine changed, but the reasons for not recommending and the fears associated with the vaccine have also significantly changed. Pre-training, the majority of the participants who did not recommend the vaccine cited increased potential side effects associated with nonavalent vaccines as the reason for not recommending it, which changed to the relatively higher cost of the vaccine post-training.

Ramavath and Olyai showed in their study conducted on the knowledge and practices of adolescent girls regarding HPV and its vaccination that structured teaching programmes in the form of health talks and group discussions can significantly improve the knowledge and potentially the practices regarding vaccination and prevention of HPV.^[4] Koshy et al., in their study investigating the knowledge about cervical cancer in female university students, showed that a proportion of medical students are also unaware of risk factors and preventive measures of cervical cancer, highlighting the importance of focused structural teaching tools regarding the same.^[5] The study by Mehta et al portrays a similar situation with medical students lacking knowledge about the pathobiology of HPV, cervical cancer, and vaccine immunology and efficacy.^[6] The scenario of KAP among healthcare providers in an urban setup was shown by Chawla et al.^[7] and Aggarwal et al.^[8] Similar findings were reported by Biselli-Monteiro et al. in medical and allied sciences university students in Brazil. Their study even reported improved vaccination rates after an education session.^[9] Fang et al. have investigated the KAP and factors influencing it among university students in various streams of study in China. They highlighted participant factors associated with rejection of the vaccine, namely male gender and socioeconomic status.^[10] Physicians primarily advocate for the vaccine, but KAP among their patients regarding vaccination and vaccine adoption can be lacking, and the lacunae are highlighted in a study by Ganeshkumar et al.^[11]

As highlighted in the above studies, physicians can majorly influence public opinion on vaccination, especially among their patients who present for other pathologies. As future physicians, medical students have to be specially sensitised towards the availability, efficacy, and safety of the newer nonavalent vaccine. As shown in our study, information regarding the nonavalent vaccine was lacking among students, and misconceptions, especially regarding its safety, were prevalent. The concerns for not adopting the vaccine shifted majorly towards the cost of the vaccine, with minor concerns stemming from potential lack of availability after the training was imparted. These concerns can be alleviated with widespread advocacy and adoption of the vaccine, which should increase availability and reduce cost due to economies of scale.

TAKE HOME MESSAGE

The nonavalent HPV vaccine is gender neutral and can be administered to 18-25 year old subjects. It is safe and effective in preventing the majority of the oncogenic HPV strains. Medical students as future physicians will play a key role in advocating for and increasing the adoption of this vaccine. Misconceptions regarding the safety of the vaccine were the major reason for not adopting the vaccine, which were effectively addressed via the training session. Focused teaching modules will improve the KAP among this key population of future proponents of HPV vaccination, thus potentially leading to widespread adoption.