Knowledge, attitude, and barriers regarding human papillomavirus vaccination and screening among healthcare professionals: A cross-sectional study

INTRODUCTION

Cervical cancer is the fourth most common cancer among women worldwide. According to GLOBOCAN 2020, there were 341,831 (3.4%) new deaths due to cervical cancer globally. Alarmingly, every minute, one woman is diagnosed with this disease. Cervical cancer has a well-defined, prolonged pre-malignant stage, which can be detected early through routine screening and timely follow-up. However, most Indian women remain unaware of these screening options.^[1]

In Uttarakhand, limited research has been conducted, despite a notably high incidence of cervical cancer. A study from Nainital and adjoining districts reported that cervical cancer is the second most common cancer among women in the region, with an average age of diagnosis being 52 years.^[2] According to ICMR data, the incidence of cervical cancer in Uttarakhand increased by 2.9%, which is higher than the national average of 2.4%.^[3]

Human papillomavirus (HPV) is a group of highly prevalent viruses worldwide, primarily transmitted through sexual contact. Cervical cancer is often asymptomatic in its early stages, though some patients may experience foul-smelling vaginal discharge and abnormal bleeding. Risk factors for cervical cancer include high parity, multiple sexual partners, early age at marriage, smoking, low socioeconomic status, poor personal hygiene, and prolonged oestrogen exposure, such as through long-term use of oral contraceptive pills.^[2]

HPV vaccination is recommended between the ages of 9 and 12 years and can be given up to 26 years of age. For Gardasil, the recommended schedule is three doses at 0, 2, and 6 months, while for Cervarix, it is 0, 1, and 6 months. If the vaccination schedule is interrupted, the next dose should be administered as soon as possible.^[4] The vaccine is administered intramuscularly into the deltoid muscle or the anterolateral thigh in a dose of 0.5 mL. In India, the HPV vaccine is not yet approved for use in males, although efficacy trials in males are currently underway. Regular cervical cancer screening is essential to reduce mortality. According to the American Cancer Society (ACS), HPV screening every five years is recommended after 25 years of age.

Screening methods for cervical cancer include the HPV test, visual inspection with acetic acid (VIA), and visual inspection with Lugol’s iodine (VILI).

There are several challenges to HPV vaccination and screening, including a lack of awareness, limited time, and inaccessibility of services. The knowledge and practices of healthcare professionals (HCPs) regarding HPV vaccination and screening are crucial, as they significantly influence their likelihood of recommending these preventive measures to others in the future. Therefore, this study was conducted to assess the knowledge, attitude, and perceived barriers related to HPV vaccination and screening among HCPs. The findings of this study can provide valuable insights at the policy level, supporting efforts to strengthen awareness and improve attitudes toward this critical public health issue.

MATERIAL AND METHODS

RESULTS

Knowledge about HPV vaccination and screening among HCPS

Only 15.1% of HCPs demonstrated good knowledge regarding HPV vaccination and screening [Figure 1]. For instance, 36% believed that HPV affects only females, and 61.7% were unaware that HPV can be transmitted through skin-to-skin contact. While 60.9% correctly identified that early onset of sexual activity is a risk factor for HPV infection, only 45.7% knew that men can transmit HPV to women [Table 1].

Table 1: Knowledge about HPV vaccination and screening among HCPs (n = 350)

Knowledge about cervical cancer and HPV	Correct f (%)	Incorrect f(%)
• Cervical cancer is caused by human papillomavirus (T)	325 (92.90)	25 (07.10)
• Cervical cancer is more common in females belonging to the age group of 35- 50 years (T)	309 (88.30)	45 (11.70)
• HPV affects only females (F)	126 (36.00)	224 (64.00)
• HPV is transmitted through skin-to-skin contact (T)	134 (38.30)	216 (61.7)
• All women are at risk of developing cervical cancer due to HPV infection (T)	216 (61.70)	134 (38.30)
• The early onset of sexual activity is a risk factor for HPV infection (T)	213 (60.90)	137 (39.10)
• A man cannot transfer the HPV infection to a woman (F)	160 (45.70)	190 (54.30)
Related to HPV vaccination
• HPV vaccination is given 0.5 mL (T)	240 (68.60)	110(31.40)
• HPV vaccination is given intramuscularly (T)	246 (70.30)	104 (29.70)
• There is only one dose of vaccine for the age group 9- 14 years for both genders (F).	84 (24.00)	266 (76.00)
• HPV vaccination is preventable against cervical cancer (T)	298 (85.10)	52 (14.90)
• Males can also be HPV vaccinated against HPV infection (T)	125 (35.70)	225 (64.30)
• A 45-year-old person can take an HPV Vaccination if not received earlier (T)	127 (36.30)	223 (63.70)
• HPV vaccination can be administered safely to a pregnant woman (F)	124 (35.40)	226 (64.60)
Related to HPV screening in women
• Screening tests are available for HPV screening in women (T)	301 (86.00)	49 (14.00)
• HPV screening in women should be performed before 25 years (F)	85 (24.30)	265 (75.7)
• All females must be screened for HPV every year (F)	81 (23.10)	269 (76.90)
• There is a need for HPV screening in women even after HPV vaccination (T)	252 (72.00)	98 (28.00)
• VIA (Visual Inspection using Acetic acid) test is for cervical cancer screening (T)	200 (57.10)	150 (42.90)
• A Pap smear screening test is used for screening and diagnosing cervical cancer (T)	301 (86.00)	49 (14.00)

f represents frequency. T for true statements, F for false statements. HCPs: Healthcare professionals, HPV: Human papillomavirus.

Close

Figure 1: Knowledge level about HPV vaccination and screening among HCPs. HPV: Human papillomavirus, HCP: Healthcare professionals.

Export to PPT

DISCUSSION

Cervical cancer is the most common cancer among women, yet it is also one of the most preventable. Effective screening is key to addressing cervical cancer.^[5] Healthcare professionals play a critical role in disseminating information on cervical cancer prevention to the wider public.

Most HCPs were aware that cervical cancer is caused by HPV, which aligns with findings from previous studies.^[6] In contrast, Tran et al.^[7] reported that only one-third were aware of this fact. Most HCPs had adequate knowledge of the risk factors for cervical cancer, as reported in various studies.^[5,6,8,9] However, studies by Tran et al.^[7], Mutyaba et al.^[10], Obol et al.^[11], and Shah et al.^[12] found that only a few healthcare workers (HCWs) had adequate knowledge of cervical cancer risk factors.

Similar to the present study, Dulla et al.^[8] And Oche et al.^[13] Also reported that the majority of HCPs were aware that cervical cancer can be detected through screening. Likewise, as reported by Anantharaman et al.^[5] Most healthcare workers (HCWs) in the current study identified the Pap smear as a screening procedure for HPV detection. However, only a very few female HCPs had undergone screening for HPV themselves, a finding echoed in multiple studies.^{[7,8,13–18]}

This low uptake of screening was attributed to various factors, including a lack of adequate awareness, fear of being diagnosed with cervical cancer, and discomfort during the procedure. It is concerning that healthcare professionals, who are responsible for promoting opportunistic screening among women, are themselves reluctant to participate in it.

The majority of HCPs in our study were unaware of the recommended cervical cancer screening intervals, similar to the findings reported by Yaren et al.^[9] and Mutyaba et al.^[10] Most HCPs in our study were aware that the HPV vaccine can prevent cervical cancer. In contrast, Dulla et al.^[8] reported that only one-third of healthcare workers (HCWs) were aware of this preventive measure.

We found that fewer participants in our study had adequate awareness of cervical cancer, HPV, HPV vaccination, and screening, compared to the findings of Dulla et al.^[8] and Anyebe et al.^[14], who reported good knowledge among healthcare workers. In contrast, Mutyaba et al.^[10] reported that health workers had very low knowledge, while Nganwai et al.^[6] found moderate knowledge levels. These variations in findings may be attributed to differences in the types of healthcare professionals involved, e.g., nurses^[6,14] and doctors^[15,16], and the healthcare settings in which the studies were conducted.

Female healthcare providers had better knowledge of cervical cancer, screening, and vaccination compared to their male counterparts, as also reported by Eze et al.^[19] This difference may be attributed to women’s greater interest in female-specific health issues. Similar to a study from Tanzania^[17], this study found that younger nurses had better knowledge about cervical cancer compared to older nurses. HCPs from urban areas had better knowledge than those from rural areas, which is consistent with the findings of Tran et al.^[7] HCPs with less than five years of work experience demonstrated better knowledge than those with more than five years of experience. This may be due to less frequent revision of previously acquired knowledge. Additionally, HCPs holding master’s degrees had better knowledge compared to those with bachelor's or diploma qualifications, possibly due to the additional exposure and learning during higher studies.

It was encouraging to observe that the majority of participants in our study held favourable attitudes toward preventive measures such as HPV vaccination and screening. This contrasts with the findings of Mutyaba et al.^[10] and Anyebe et al.^[14], where participants demonstrated negative attitudes. However, despite the positive attitude seen in our study, only a few participants had undergone HPV screening. This suggests that while attitude is important, it alone is not sufficient to bring about a change in individual health behaviour.

A variety of factors contribute to modern vaccine hesitancy. In our study, the most common barrier perceived by healthcare providers (HCPs) regarding HPV vaccination was a lack of knowledge. Knowledge gaps among HCPs limit their ability to educate patients effectively. Other major barriers identified included the absence of nearby HPV vaccination centres and concerns about vaccine side effects. HCPs are widely recognised as trusted sources of medical information, and their influence is critical in improving vaccination rates. However, factors such as high vaccine cost, lack of time, and fear of pain were also reported to discourage HCP participation in HPV vaccination. These perceived barriers contribute to low vaccination coverage, missed opportunities, and a lack of professional recommendations. According to Palmer et al.^[20] Implementing school-based vaccination requirements can be an effective strategy to increase immunisation uptake.

Similar to the findings of Devarapalli et al.^[21] The present study also identified a lack of knowledge as the most common barrier perceived by HCPs regarding HPV screening. This was followed by fear of being diagnosed with cervical cancer. The third most commonly reported barrier was a sense of discomfort during the screening process. Other barriers identified included embarrassment or shyness, lack of time, and lack of family support.

TAKE HOME MESSAGE

The study revealed that healthcare professionals have very low rates of cervical cancer screening and HPV vaccination, despite being expected to serve as role models in health service utilisation. To address this, it is essential to consider integrating cervical cancer screening and HPV vaccination into routine reproductive health services. Efforts should be made to enhance awareness through targeted health education. Increasing healthcare professionals’ knowledge and awareness about cervical cancer, the importance of HPV vaccination, and regular screening is crucial for improving both practice and advocacy.