CHAPTER-II

REVIEW OF LITERATURE

The literature review is a methodical hunt of a published studies

to get information on the subject of the research topic (Polit &
Beck, 2008)1977, Undertaking review of literature is an exigent
but instructive experience. A review of literature entails the
detection, collection, critical investigation, and reporting of all
that is known regarding the topic under study. Through the
review, the researcher creates a representation of what is
known about a specific condition. The knowledge gap between
the problem and the research topic is analyzed. This lays the
foundation for the research plan.
The researcher planned to review the available literature on
HPV vaccination and prevention of cancer with a focus on
research and non-research. articles. Detailed review of the
studies on the educational interventions for parents of
adolescents was done. The reviewer intended to get a broad
knowledge base about HPV infection, HPV vaccination, and the
effect of educational interventions on the knowledge and
attitude of parents of adolescents about HPV vaccination
.
Review of literature is grouped and presented in the following
sections.
Section A : HPV infection and cancer
Section B HPV vaccination and prevention of cancer
Section C Awareness, knowledge and attitude of parents on HPV
vaccination
Section D Effect of educational interventions on the knowledge
and attitude of parents regarding HPV vaccination.
2.1 Section A: HPV infection and cancer
This section compiles the studies from the existing literature
which deal with human papillomavirus infection and its
relationship with the different types of cancers it may cause.
Eduardo L. Franco, et al., in their study on Epidemiologic Evidence and
HPV Infection, has stated that unlike most cancers, where biological &
lifestyle determinants contribute to carcinogenesis, the vital causal
agent for cancer of the cervix was identified as the human
papillomavirus (HPV) infection. Based on the evidence from an
international collaborative study by F.Xavier et al., they identified 93%
prevalence of HPV DNA in cervical tumors. The study included more
than 1000 specimens from cervical cancer patients that used a highly
sensitive polymerase chain reaction (PCR) protocol.16)

A study titled 'Prevalence of HPV in Cervical Cancer: a Worldwide

Perspective" was conducted by F. Xavier Bosch, et al., to determine if
the relationship between HPV infection and cervical cancer is constant
worldwide. From 22 countries, more than 1000 specimens from
chronological patients with invasive cancer of the cervix cancer were
collected, frozen, and stored. A central histologic review was done on
these slides to validate the diagnosis and evaluate the histologic
characters. In 93% of the tumors, HPV DNA was detected. There was no
noteworthy disparity in HPV positivity between countries. HPV 16 was
present in 50% of the specimens, HPV 18, in 14%, HPV 45 in 8%, and
HPV 31 in 5%. HPV 16 was the prime type in most countries except
Indonesia. In Indonesia, HPV 18 was more common. Among squamous
cell tumors, HPV 16 dominated (51% specimens), but in
adenocarcinomas, HPV 18 dominated (56% tumors) and
adenosquamous tumors (39% tumors) 10

Meichang Ai, in his paper on the association between HPV infection and
cervical cancer progression, said that among many individual causative
factors, HPV infection was most vital. It is widespread among females of
suitable ages, and only persistent HPV infection is essential to cause
cervical cancer, 1701

In his study on the advances in HPV infection and oropharyngeal cancer.

Zhitao Guo summarized the research developments on HPV infection
and carcinogenesis method, remedial effect, and prospects of
oropharyngeal epithelium. Using PubMed and Medline database,
relevant literature was searched from 1998. January to 2012 June. The
results were incorporated into the criterion of biological characters of
HPV, carcinogenic method and mode of HPV spread, HPV infection
rate, HPV infection and prospects of the HPV vaccine, According to the
integrated
criteria, 38 articles were analyzed.
It was found that HPV infection was a central risk and self-
determining prognostic cause of oropharyngeal cancer,
In a paper by Catherine de Martel, Martyn Plummer, Jerome Vignat,
and Silvia Franceschi (2017), they wrote on the universal burden of
cancer attributed to HPV by site, country, and HPV type. They
mention that HPV is the reason of approximately every cervical
cancer, HPV is also responsible for a considerable portion of
anogenital and oropharyngeal cancers. Of all cancers worldwide,
4.5% (630,000 new cancer patients diagnosed every year) are
because of HPV: 0.8% in men and 8.6% in women, Of HPV-
attributable cancers, 83% are in the cervix. Other HPV-attributable
cancers include 8500 in the vulva, 12000 in the vagina. 35000 in the
anus and 13000 in the penis. HPV-attributable cancers in the head
and neck include 38000, of which 21000 are oropharyngeal caneers.
They occur mostly in developed. countries. The burden of HPV 16 or
18, and the likelihood of cross-protection stress the significance of
introducing inexpensive vaccines in less developed countries. 1721
A study including 395 woman from quilombo communities, users of
the united health scheme in Brazil, to screen them for cervical
cancer and identify the prevalence of HPV infection in Brazil was
done by Nascimento MDDSB, Silva MACND. Vidal FCB, et al. About
12.6% of women had HPV infection. Infection by high-risk type of
HPV was common. The main prevalence of HPV infection was in
women with a high-grade squamous intraepithelial lesions (42%),17
2.2 Section B: HPV vaccination and Prevention of Cancer
Elissa Meites, Allison Kempe, and Lauri E. Markowitz (2016) wrote
on the updated Recommendations of the Advisory Committee on
Immunization. Practices Use of a 2-Dose regimen for HPV
Vaccination. They say that routine HPV vaccination is recommended
at 11 or 12 years of age since 2006. They undertook a systematic
review to spot studies on humans that documented any key
statistics on the serious health effects after two-doses of HPV
vaccination. The outcomes under study were seroconversion,
antibody avidity, or geometric mean titers.
It was found that
among 1,377 participants who received the two-dose
gardsail9 vaccine, more than
97.9% seroconversion was seen by four weeks after the last dose.
The geometric
mean titers were more for persons aged 9-14 years compared to
persons aged 16-26
years. Hence they recommend that routine vaccination of boys and
girls after nine years of age is good, although it can be continued up
to 26 years of age. Contraindications for the vaccination are
pregnancy and any adverse reactions. following vaccination.[74]
An article on the human papillomavirus and vaccination, the most
common STI in the United States, was written by Huang CM.
Modeling estimates suggest that by 50 years of age, above 80% of
sexually active women will get genital HPV. Though majority of the
infections are transitory and without symptoms, long- standing
infection with high-risk HPV types may cause precancerous lesions
that may develop in to cancer. In June 2006, the first vaccine to
avert cervical cancers and related illness in women was licensed by
the US Food and Drug Administration. This vaccine protects against
HPV 6, 11, 16, and 18. These HPV types are responsible for 90%
genital warts and 70% cervical cancers. Numerous research articles
have been. published investigating the vaccine's effectiveness,
extent, immunogenicity, and protection. It is good to vaccinate
children with HPV vaccines to prevent the spread of infection and
produce herd immunity, 1751
A study to assess the effect of quadrivalent HPV vaccine with the
occurrence of condyloma or genital warts was done by Leval A,
Ploner A, Herweijer E, et al. in 2013. This is the initial probable
disease to measure the effect of HPV vaccination approaches. They
studied a total of 124000 girls and women were vaccinated
between 2006 and 2010. To identify the effectiveness of the
vaccine, the incidence ratios of genital warts were estimated with a
time-to-event analysis. It was found that the vaccine effectiveness
was 76% amid individuals who got three vaccine doses before 20
years of age. It was also found that the effectiveness of the vaccine
was the maximum when girls were immunized before 14 years of
age. They concluded that young age at the time of vaccination was
essential for the effectiveness of the quadrivalent vaccination. [6]
Rengaswamy Sankaranarayanan, Priya Ramesh Prabhu, Michael
Pawlita, Esmy PO. Tarik Gheit, Neerja Bhatla, et al. performed a
multi-centre prospective study among Indian girls to identify the
immunogenicity and infection. with HPV after one, two and three
doses of the quadrivalent vaccine. The study was. carried out at
nine locations in India in unmarried girls 10-18 years of age. 17729
girls

were recruited and vaccinated in four cohorts. A total of 4348 girls

got three doses (25%), 4979 got two-doses (28%) on days 1 as well
as 180 or later, 3452 got two- doses (19%) on days 1 and 60, and
4950 got one dose (28%). The study confirmed that two doses of
quadrivalent HPV vaccine, given with a gap of 180 days or more, are
immunologically not substandard to the three-dose schedule. The
findings supported the recommendation of the WHO on providing
two-doses with an interval of six months for regular immunization
of young girls, 1771
Akanksha Rathi, Suneela Garg, and GS Meena wrote a review article
on Human Papilloma Virus Vaccine in Indian Settings: Need of the
Hour. They say that Cancer of the cervix is a key public health
problem causing a fifth of the worldwide incidence and death. The
necessary cause for the advance of cervical cancer is long-standing
HPV infection. Other factors in concurrence with HPV infection
increase the risk. Factors leading to soaring prevalence of cancer
cervix in India are countless. Nearly half of Indian women (45%)
concerned about becoming obese than getting cancer (24%).
Vaccination is an approach to prevent this. Advisory bodies like the
'Indian academy of pediatrics (IAP) and the "federation of obstetric
and gynecological societies of India (FOGSI), have suggested HPV
vaccination. However, only some young girls get the vaccine as it is
costly and is mainly administered in the private sector. India should
include the HPV vaccination in the national immunization list to
bring down the prevalence of cervical cancer. 176
A systematic review was done by Rambout L. Hutton B, Hopkins L.
and Fergusson D to identify information about the prophylactic
immunization against human papillomavirus infection and to gauge
the potential impact on the disease burden. The reports in five
electronic databases covering the studies from 1950 to 2007 were
screened. Of the 456 screened reports, six RCT and three follow-up
studies. of preliminary trials were reviewed. Meta-analysis was
done, and the findings showed. that prophylactic HPV vaccination
was related with a fall in the incidence of high- grade cervical
lesions caused by HPV strains, when compared with the control
groups. The vaccination was highly efficacious in preventing HPV-
related infections and disease result which included persistent HPV
infection, genital warts, and low- grade lesions. Adverse reactions, if
ever they occurred, were minor. The study
concluded that in the midst of females aged 15-25 years, not
formerly infected withwere recruited and vaccinated in four
cohorts. A total of 4348 girls got three doses (25%), 4979 got two-
doses (28%) on days 1 as well as 180 or later, 3452 got two- doses
(19%) on days 1 and 60, and 4950 got one dose (28%). The study
confirmed that two doses of quadrivalent HPV vaccine, given with a
gap of 180 days or more, are immunologically not substandard to
the three-dose schedule. The findings supported the
recommendation of the WHO on providing two-doses with an
interval of six months for regular immunization of young girls, 1771
Akanksha Rathi, Suneela Garg, and GS Meena wrote a review article
on Human Papilloma Virus Vaccine in Indian Settings: Need of the
Hour. They say that Cancer of the cervix is a key public health
problem causing a fifth of the worldwide incidence and death. The
necessary cause for the advance of cervical cancer is long-standing
HPV infection. Other factors in concurrence with HPV infection
increase the risk. Factors leading to soaring prevalence of cancer
cervix in India are countless. Nearly half of Indian women (45%)
concerned about becoming obese than getting cancer (24%).
Vaccination is an approach to prevent this. Advisory bodies like the
'Indian academy of pediatrics (IAP) and the "federation of obstetric
and gynecological societies of India (FOGSI), have suggested HPV
vaccination. However, only some young girls get the vaccine as it is
costly and is mainly administered in the private sector. India should
include the HPV vaccination in the national immunization list to
bring down the prevalence of cervical cancer. 176
A systematic review was done by Rambout L. Hutton B, Hopkins L.
and Fergusson D to identify information about the prophylactic
immunization against human papillomavirus infection and to gauge
the potential impact on the disease burden. The reports in five
electronic databases covering the studies from 1950 to 2007 were
screened. Of the 456 screened reports, six RCT and three follow-up
studies. of preliminary trials were reviewed. Meta-analysis was
done, and the findings showed. that prophylactic HPV vaccination
was related with a fall in the incidence of high- grade cervical
lesions caused by HPV strains, when compared with the control
groups. The vaccination was highly efficacious in preventing HPV-
related infections and disease result which included persistent HPV
infection, genital warts, and low- grade lesions. Adverse reactions, if
ever they occurred, were minor. The study concluded that in the
midst of females aged 15-25 years,not formerly infected withmost
of the public are unaware that HPV infects both males and females
and vaccine is offered for both genders, the community should be
taught on this, (2)

2.3 Section C: Awareness, knowledge, and attitude of parents on

HPV vaccination
A population-based study to explore the dynamics linked with HPV
awareness was conducted by "Romaquera J, Caballero-Varona D.
Tortolero-Luna G, Marrero E, et al., among 16 to 64 year old
females from the minority Hispanic community at Puerto Rico. A
sample of 566 women was assessed for their sexual activities, HPV
awareness, and HPV vaccination. About 64.8% of the women had.
awareness on HPV vaccination. Among the age group of 16-26
years, 4.7% had received at least one dose of the vaccine. Most of
them had heard through the media, while 39.6% had heard from
their physicians. The study concluded that awareness among
Hispanic women is low and recommendations from physicians and
educational efforts are important to increase awareness in the
targeted group, 183)
A meta-analysis was done by Zhang Y, Liu L, Wang Y, Fan Y, and Nie
S, in China, including 58 studies to know about the awareness of
HPV vaccination and its acceptance. Two English and three Chinese
electronic databases were searched. The results showed that the
collective knowledge and awareness rates about were 17.55% and
15.95%, respectively. Women displayed higher awareness than
men. The parent population (33.78%) was less willing to vaccinate
their girl child than general population (64.72%). Safety (50.46%)
was the major apprehension among the adults. The primary
concerns for unwillingness to vaccinate their daughters were safety
and efficacy (68.19%). The study concluded that low awareness and
knowledge was seen among the people in China,
A systematic review of studies on knowledge, attitude and behavior
of parents towards HPV vaccination was done by Kristina Trim,
Katherine Roy, Laurie Elit, and Naushin Nagji. A total of 254 articles
were included. It was found that 37% of parents were anxious
about the safety of the HPV vaccines, and 25% of them wanted
more information. In 16 studies, 30% of parents concerned about
the potential risk of cancer were willing vaccinate their children.
This study concluded that parentswant to know more from their
physicians and a reassurance on the safety of the vaccine, Des
Chan Z C, et al., did a systematic review to observe and portray
women's knowledge of HPV vaccination and attitude towards the
same. The studies published between 2005 and 2010 were
included. Methodological qualities were assessed using the "Critical
Appraisal Skills Program (CASP)" tool. Thirty-six articles were
reviewed. The concepts were extracted under four main themes.
Under the theme, attitudes and intentions toward HPV vaccination,
it was found that most women had high intentions and positive
attitudes toward HPV vaccination, Factors like knowledge about
vaccination, safety, cost, and efficacy affect the woman accepting
the vaccination. The knowledge is poor in many women. 196
A systematic review was done in Sub-Saharan Africa by Stacey
Perlman et al., to identify the knowledge of the HPV vaccine and its
uptake. Peer- reviewed studies conducted from 1990 to 2011 were
taken from the "World Health Organization database. The review
discovered that the willingness to vaccinate was high but the
knowledge and acquaintance of cancer, HPV, or vaccine was low.
The study concluded that there is a pressing demand to educate
people through education, specifically to adolescents, their parents,
and health care workers. Education can help to encourage
acceptability of HPV vaccines so that the HPV vaccination programs
are successful. (87)
A systematic review addressing the barriers to human
papillomavirus vaccination among adolescents in the US was
performed by Dawn Holman, Katherine Roland, Vicki Benard. Meg
Watson, Shannon Stokley, and Nicole Liddon. The studies from
PubMed after 2009 were targeted. Fifty five articles were identified
and reviewed. The findings showed that health care professionals
mentioned financial concerns and parental attitudes as barriers to
HPV vaccination. The parents cited that their lack of information
was a barrier and professional recommendation from health care
workers is a significant factor in their choice to vaccinate their
children. This study concluded that sustained hard work is
necessary to make sure that health-care workers and parents are
well informed and understand the importance of HPV vaccination

A mixed method synthesis of survey and qualitative data from 12

electronic databases between 1980 to 2011 that included 28
qualitative studies and 44 surveys was done by Maggie Hendry, et
al. It was found that wherever vaccination. was offered, the
utilization was high. There was poor knowledge with many
misconceptions. Participants were could not tell about HPV in the
perspective of its sexual transmission and cancer. Many girls and
parents had limited understanding of vaccination to decide about
HPV vaccination. They suggested that the right information should
be passed on to parents to help them know about HPV vaccination
and make informed choices.
A review to consolidate the findings of researches conducted with
African American and Latinos related to the factors related with
HPV vaccine acceptance using an integrated review approach was
done by Kayoll V Galbraith et al. The databases used were
"PubMed, Cumulative Index to Nursing and Allied Health Literature,
and PsycINFO". The results showed that the demographics of the
parents affected their awareness about HPV and HPV vaccination.
There was an association between higher socioeconomic status and
awareness. The cancer prevention role of the vaccine and a
provider's counsel were associated with vaccine acceptability.
Culture-centered theories should be used to develop a culture-
grounded intervention to increase awareness and vaccine
acceptability, 1901
A systematic review to understand the factors that influence
parents of adolescents acceptance of the HPV vaccine in the
Association of South East Asian Nations (ASEAN) region was
performed by Kurnia Eka Wijayanthi, Heike Schutze, Catherine
MacPhail, and Annette Braunack- Mayer. Seven databases were
explored for studies published up to 2020 which were peer-
reviewed. The theory of planned behavior framework was used to
analyze the answers to the review questions in sixteen publications.
When the vaccine was given free of const, the attitude of parents
was positive, the vaccine acceptance was high, and the vaccine
uptake was increased. This study concluded that even though
parents had inadequate knowledge of cancer and the HPV vaccine,
they were willing to vaccinate their children if the vaccine was
offered for free, 1911
A meta-analysis of certain studies were done by Peter A Newman,
Carmen H Logie, et al., to study the factors linked with parents
vaccinating theirfathers on vaccinating their children. Two studies
showed that fathers awareness was less compared with mothers, and
their HPV knowledge was also low, 195)

A cross-sectional study to identify the HPV vaccine uncertainty amongst

parents of adolescents was done by Giorgia Della Polla, Concetta Paola
Pelullo, et al., in Italy. A self-administered questionnaire was employed
to gather data. Almost 66.7% of parents had beard about HPV
vaccination. Parents whose daughters were vaccinated had more
knowledge of HPV. The majority of parents (88%) said that
immunization was valuable and parents who knew regarding HPV had a
higher and had received information from health care workers. This
study concluded. that communication and education strategies should
be undertaken to ensure that the parents are fully aware of the HPV
vaccine and its benefits. Health care workers should provide this
information and educational materials to inform parents, (96)

A study on the title, "A new strategy for cervical cancer prevention
among Chinese women was conducted by Yu Huang, Shuiyang Xu, et al.,
to identify how much Chinese women know and how they react to HPV
vaccination. The investigation was done for the parents of students in
the high school to evaluate their knowledge of cervical cancer, HPV
infection, and its vaccine through a pre-tested questionnaire. A total of
1125 parents responded, of which 87.5% said that cervical cancer the
most widespread genital cancer and 78.67% said that HPV leads to
cancer. Only 54.3% said that HPV vaccination is available, and 35.6%
said that they are sure when to vaccinate their children. Of the samples,
4.4% had given the vaccine to their daughters, and 35.4% were ready
for vaccination. The parents' knowledge level of cervical cancer was low
regarding HPV and its vaccination. Their Vaccine acceptance was also
low. Hence they recommended that awareness programs and
education are necessary to firm up the HPV vaccination program in
China. 197)

A cross-sectional analysis was done by Lixia and Junyong, among

women in western China to study their knowledge and acceptability of
the HPV vaccine. Questionnaires were circulated among 1300 women,
and 1109 women. completed it. Of those who completed, 28,85% had
heard about HPV, and only 8.3% had correctly answered all the
questions on HPV. More than half of the women

(51.2%) said that they would be willing to be vaccinated against HPV.

The study.
concluded that although women lacked basic knowledge about HPV,
many werechildren who were less than 18 years of age. Seventy
nine studies from 15 countries on 8, 40, 838 parents were
incorporated in the analysis. It was found that 41.5% of parents had
vaccinated their children and the vaccination uptake was two times
more in girls (46.5%) than in boys (20.3%). In 62 studies, physician
recommendation (r=0.46) had the most significant influence on
parent's uptake, followed by the parent's beliefs in vaccines (r=
0.19). The findings indicated suboptimal levels of HPV vaccine
uptake. This can be increased by promoting parents positive beliefs
about the vaccine through education. (92)
A systematic review of the knowledge, attitude and perception of
parents towards HPV vaccination was undertaken by Faeza Netfa, et
al. Major bio- medical databases were searched, and 19 studies
containing data on 2206 adults were included. Participants
knowledge in many studies was limited. Attitudes, assessed in. 13
studies were mixed. This study concluded that knowledge of HPV-
related diseases and their vaccination was generally low. A taylor-
made health education program on the efficiency and safety of the
vaccination targeting parents is suggested. (93)
A systematic review to discover the factors related with parents"
attitudes toward the vaccinating their adolescent boys was done by
Gorjana Radisic, Janine Chapman, Ingrid Flight, and Carlene Wilson,
using the health Belief Model 10 organize the findings and semi-
quantative method to summarize them. Eighteen studies were
included in the review, and it was found that the predominant
factors that influence parental decisions were apparent advantages
of the vaccine, risk of acquiring the disease, and suggestion from
health-care providers. Knowledge about the vaccine was identified
as an essential factor when deciding whether to vaccinate the boys.
This study explained that the uptake of the HPV vaccine among
adolescent boys is suboptimal. Hence it is vital to educate the
parents regarding the vulnerability to infection, and the advantages
of vaccination, 1941
An integrated review to identify, synthesize and explore the HPV.
beliefs, attitudes, and acceptance of fathers of Latin origin was
undertaken by Paloma Suarez, et al. A total of 10 studies, including
fathers and mothers, were identified from the electronic database
and analyzed using the matrix method. A recommendation from the
physician is a factor that would impact the attitude ofwilling to take
the vaccine. Hence the researchers recommend that efforts to
educate. the public should be taken, 19
A study was conducted in Romania to evaluate the knowledge and
attitude on the HPV vaccine among parents by Septimiu Voidazan,
Monica Tarcea, Silviu-Horia Morariu, Adelina Grigore, and
Minodora Dobreanu. It was done in three schools. Of the 918
parents, 85.8% said they have listened to information about HPV
vaccination from specialized health care professionals (39.1%) and
through internet. browsing (42.9%). The fear of side effects is the
main reason for not wanting to vaccinate their child. The study
concluded that the acceptance of vaccination requires effective
implementation of educational strategies to parents and their
children. 1997
A cross-sectional survey among the parents of school children was.
undertaken by Wei Wang, Yuanyuan Ma, et al to find out their
awareness on HPV vaccine. Of the 400 parents were covered by
using cluster sampling, 22.63% had heard of HPV, and 10.2% had
knowledge regarding HPV vaccine. Only 40.8% of parents were
ready to immunize their children, and 60% supported promoting
HPV vaccination as they believed that it could prevent cervical
cancer, genital warts, or anal cancer. They concluded that parental
awareness and willingness for vaccination were low though the
general attitude of parents towards HPV vaccine promotion was
encouraging, 100
A study with the objective to evaluate the knowledge of cancer
cervix among women in Bangladesh and their readiness for HPV
vaccination was done by Islam JY, Khatun F. Alam A, Sultana F,
Bhuivan A, Alam N, et al, with 2037 married women. The women
were assessed on their knowledge of cervical cancer and their
willingness to get the HPV vaccination. Most of the women stated
that they had heard about cervical cancer. But, only a few women
(6.4% in urban and 4.4% in rural) reported that they have detailed
knowledge of the risk factors of cervical cancer and its prevention.
Among the urban women, those who were educated above
secondary school and those with high socioeconomic status had
heard about HPV vaccination. The readiness of the women to
receive the HPV vaccine for themselves or their
daughters was high, 93.9% in urban and 99.4% in rural parents, for
themselves. In
urban area, 91.8% of parents and in rural area, 99.2% of parents
were ready toimmunize their daughters. This study concluded that
instruction on cervical cancer in detail with a focus on the HPV
vaccine is important in preventing cervical cancer,
A descriptive comparative study to assess the Korean American
parents HPV awareness and perception of HPV vaccination and to
differentiate the knowledge and perception about HPV vaccination
between the parents who have immunized their adolescents and
those who have not vaccinated them was done by Young-Me Lee,
et al. The result showed that the general knowledge about HPV
vaccination was deficient. The mean score was 3.14 on a total score
of 10. Parents. also reported a negative opinion towards HPV
vaccination and there was no significant difference between the
knowledge of the parents who had vaccinated their children and
those who had not. But there was a significant difference between
the perceived benefits and barriers to vaccination. The study
concluded that inadequate knowledge and pessimistic opinion on
HPV vaccination prevented parents from vaccinating their children.
Creating a culturally appropriate HPV education program is vital to
advance and employ preventive actions for HPV,
A study was conducted by Ana Cristina Lindsay, et al., among
immigrant parents in Central America to identify their
understanding, acceptability. and readiness to vaccinate their
children against HPV. A total of 56 participants were enrolled and
completed a survey. Of the parents. 75% said they had heard about
HPV vaccination. The awareness of mothers was more than fathers
(87.5% vs. 58.3%). More than 90% of the parents said they are
willing to immunize their kids if prescribed by their child's doctor.
Though it was a study with limitations, it served as a helpful step in
developing a knowledge foundation for designing future researches
and creating educational interventions.10)
A qualitative study on the sexual behavior and the knowledge of
HPV and its vaccination amongst adolescents and their parents was
done by Maria. Gonzalez-Cano, et al., in Andalusia. Discussion with
a total of 137 adolescents in fifteen focus groups and 37 parents in
five focus groups were conducted. Three major results were
identified. Communication between adolescents and their parents
on the subject of sexual behavior is lacking. Knowledge of HPV
vaccination was scarce in both groups, and parents mistrust the
vaccines as verified information is not availableto them. This study
stressed the need for detailed evidence-based information on HPV
vaccination, 10
A study to understand the health beliefs of African-American
parents and their daughters towards HPV vaccine acceptance was
undertaken by Kayoll V Galbraith-Gyan, et al., with the health belief
model as a guiding framework. A total of 30 Afro- American parents
and their daughters were interviewed personally, and the data was
analyzed using principles of "grounded theory, theoretical sampling,
and constant comparison analysis". Mothers and their daughters
perceive that the HPV vaccine is advantageous in defending against
warts and cancer cervix. Parents emphasized on the protection that
the vaccine grants against genital warts. This study concluded that
to develop suitable HPV vaccine initiatives, a good understanding of
the health beliefs that promote vaccine acceptance is essential, 100
A cross-sectional study was conducted by Maria Grandhal, et al., in
Thailand to identify parents knowledge, viewpoint, and reception of
HPV vaccination and associate them with their socio-demographics
and religious values. This was a school-based survey where the
parents of daughters completed a questionnaire. A total of 359
parents participated, and 301 samples were analyzed. The results
demonstrated that the awareness of HPV and HPV vaccination was
definitely related to the HPV and cervical cancer knowledge. The
knowledge was not significantly related to the barriers. Parents
with religious beliefs were more favorable to HPV vaccination. The
overall acceptance of vaccines was high. (106)
In India, at Mysore, a study to compare the attitude of parents and
their idea about cervical cancer, human papillomavirus, and HPV
vaccine among the urban and rural vicinity was conducted by
Abraham Degarege, et al. A total of 1609 parents of school going
adolescent girls, 778 from an urban area and 831 from a rural area,
were included in the study where the parents completed a self-
administered questionnaire. It was found that 73.6% of parents had
not heard about HPV, and 62.7% never knew that their kids could
be infected by HPV or get cervical cancer (64.1%) in the future. The
urban parents believed that HPV infection can lead to severe
outcomes (aOR 2.69). The study concluded that parents living in
rural area may be hesitant to advocate immunization for their
daughters
A study to find the influence of the sources of details on the
parental attitudes on HPV vaccine uptake in adolescents was
undertaken by Natasha Underwood, Lisa Gargano, Samantha
Jacobs, et al. It was a 3-arm randomized controlled trial with 360
parents of adolescents studying in high school. Data collection was
done through phone and an online survey. Almost 53% of the
parents said that their kids had got a minimum of a single dose of
HPV vaccination. The parents stated that the top source of
information was from medical professionals (80%) and television
(64%). There was a relationship between the source of information
and parental attitudes. The findings highlighted the significance of
the origin of information and parental attitudes, 11221
2.4 Section D: Effect of educational interventions on the knowledge
and attitude of parents regarding HPV vaccination
.
A systematic review to evaluate and summarize the evidence for
educational activities to improve HPV vaccination acceptance was
performed by Linda Y. Fu, et al. There were 33 HPV studies
identified with educational interventions in which seven tested the
effectiveness of interventions with parents. With young adults it
was eight studies and 18 studies on comparison between
adolescents, young adults, and their parents. Most of the studies
required the participants to be literate. The study did not identify
any specific educational intervention for widespread
implementation and recommended further studies to design and
test culturally competent educational interventions, 1121
A systematic review of the studies on the interventions undertaken
to increase HPV vaccine coverage to evaluate the effects of the
interventions were done by Edison J Mavundza, et al. as the HPV
vaccine coverage remains low despite the availability of effective,
safe vaccines. Thirty-five studies fulfilling the inclusion criteria were
reviewed from "Cochrane Central Register of controlled trials,
Pubmed. Web of Science, Scopus, and WHO International Clinical
Trials Registry Platform".. Review results showed that narrative
education, training, feedback, and multicomponent interventions
are a few of the interventions which improved vaccine coverage
and were conducted primarily in high-income countries. The need
for similar studies in the low and middle-income countries was
stressed in the study, 1124
A systematic review on the outcome of school-based educational
programs in the adolescent population on HPV vaccine acceptance
was conducted by Terri Flood, Iseult M Wilson, Gillian Pure, Marian
McLaughlin, and Ciara M Hughes, Randomized Controlled Trials and
Quasi-experimental studies from 2007 to 2019 were searched, and
15 studies were included for analysis. The study findings confirmed
a statistically important enhancement in a minimum of one key
outcome, such as knowledge, attitude, or vaccination. The text was
mainly focused on cervical cancer and a few on cancers in men
caused by HPV. The researchers concluded that a mixed-gender
educational program should be established for teenagers. (125)
A study to assess the effects of HPV and HPV vaccine education
program for parents, health care workers, and school employees
was done by Paul L. et al. 376 parents, 118 health care workers and
456 school employees was enrolled in the study and participated in
the class, and filled-up self-administered surveys. The results
showed that the samples had low HPV and HPV vaccine knowledge
before the program. The educational program improved the self-
rated knowledge among all the participants. After the intervention,
most of the participants believed that HPV and HPV vaccine
education is important and middle schools are appropriate venues
for this intervention. Educational programs are a simple but
efficient approach for maximizing HPV vaccination and gaining
support for school-based vaccination. 1126)
The impact of school-based education regarding cervical cancer on
perceptions about HPV vaccination among adolescent girls at Hong
Kong Chinese was studied by Tracy TC Kwan, et al. A total of 953
adolescent girls participated in a tailored educational program. The
awareness, attitude, and apparent social norms regarding HPV
vaccination and their intent to be immunized were measured
through questionnaires before and after the education. The
participants knowledge and attitude improved after participating in
the program. They concluded that the educational program had a
constructive impact on the girls opinion towards HPV vaccination
and their readiness to be vaccinated. A possible way to address the
educational requirements of adolescents is school-based education
programs. Educating the families can have a positive impact too,
11277
A technology-mediated educational program for parents was
evaluated through a study by Beth Sundstrom, et al. This study
tested a "collaborative onlinelearning environment to cultivate HPV
vaccine champions". It was a mixed method. study with three
online synchronous focus groups, including a pre and post-test and
a six month follow-up. Most of the parents were mothers. There
was statistical disparity in the knowledge of HPV and HPV
vaccination among the pre and post-test. The confidence of parents
had increased through the technology-mediated intervention.
Those encouraged them to talk liberally about HPV vaccination in
person or online. The study concluded that public media is a
suitable means to empower parents to address issues of vaccine
uncertainty and misinterpretation of HPV vaccine details
A controlled, quasi-experimental, mixed method study to evaluate a
technology-mediated HPV vaccine awareness intervention among
college-aged men and women was done by Heather M Brandt, et al.
A new, technology-mediated, social media based program was
evaluated to encourage HPV vaccination in the midst of college
students. A total of 58 students were randomized into two groups
receiving different interventions for cancer prevention- one on HPV
vaccination and the other on healthy weight control. There were
eight technology-mediated sessions with weekly e-mails and private
Facebook group posts. It was found that the knowledge of the
participants in the HPV vaccination intervention arm was more
compared with the control arm. The participants engaged with
interest and high satisfaction. The results suggested that college
students can be reached with educational interventions using the
social media platform to increase awareness of HPV vaccination.
1129
To understand the improvement of parents awareness, knowledge,
perception, and acceptability of HPV after a structured-educational
intervention, Mei Neni Sitaresmi, et al., conducted a study with 506
parents of primary school girls studying in 5th and 6th grade,
enrolled using proportional random sampling. The parents were
educated using a structured teaching program by a pediatric
resident on HPV and its vaccination. Of the parents 49.2% and
48.8% had heard about HPV infection and HPV vaccine before the
education. Noteworthy improvements were seen in parents
knowledge, awareness, and perceptions of HPV infection, cancer,
and HPV vaccination. The acceptability of HPV vaccination increased
from 74.3% to 87.4%. This study concluded that a planned
educational program might increase theawareness, knowledge, and
perception of parents towards HPV vaccination and impact the
acceptability of the vaccine, (130
A school-based education program regarding HPV and its vaccine
was given by Chun-Rong Liu, et al. They assessed its effectiveness
on the knowledge and attitude of junior middle school children,
who were selected by convenient sampling. All participants were
administered a self-administered questionnaire followed by power
point oriented health education for the intervention group. They
also completed a post-education questionnaire and follow-up
survey after one year. A total of 1675 students participated in the
study and 34.3% had previous information about cervical
cancer/genital warts, and only 15.1% had ever heard about HPV.
But 55.2% of students were willing to be vaccinated even before
the intervention, and after the intervention, 88.4% were willing to
be vaccinated. However, it decreased significantly after one year.
The study concluded that the baseline knowledge among students
HPV, its vaccine, and cancer was less. Education is effective in
raising the understanding of HPV and readiness to vaccinate.
Frequent health education at short intervals should be given, 11311
A multi-center study to identify the effectiveness of a school-based
educational program on HPV and HPV vaccination on the
knowledge and acceptance of vaccination among Chinese kids who
were 13-14 years of age was undertaken by Xi Zhang, et al. After
pre-test, the adolescents in the intervention group were given a 45-
minute talk on HPV and its vaccination. They completed a post-talk
questionnaire and after one year, the post-talk questionnaire was
given again. The initial knowledge was very poor (12.6%). About
15.7% of students had previous information HPV vaccines. Still, the
knowledge was notably more in students educated in the
intervention group. Students with higher knowledge were more
willing to be vaccinated. The study concluded that knowledge and
awareness are generally deficient in this population, and
incorporating HPV health education in the school program can
increase knowledge and vaccine uptake. 1132
A multi-center, study aimed at understanding the effect of
educational program on HPV knowledge and attitude regarding HPV
vaccines in health care workers (HCW) in western China was
performed by Hui Chen, et al. A total of 1448 health care workers
were enrolled and attended the educational lectures. In
generalfathers on vaccinating their children. Two studies showed
that fathers awareness was less compared with mothers, and their
HPV knowledge was also low, 195)
A cross-sectional study to identify the HPV vaccine uncertainty
amongst parents of adolescents was done by Giorgia Della Polla,
Concetta Paola Pelullo, et al., in Italy. A self-administered
questionnaire was employed to gather data. Almost 66.7% of
parents had beard about HPV vaccination. Parents whose daughters
were vaccinated had more knowledge of HPV. The majority of
parents (88%) said that immunization was valuable and parents
who knew regarding HPV had a higher and had received
information from health care workers. This study concluded. that
communication and education strategies should be undertaken to
ensure that the parents are fully aware of the HPV vaccine and its
benefits. Health care workers should provide this information and
educational materials to inform parents, (96)
A study on the title, "A new strategy for cervical cancer prevention
among Chinese women was conducted by Yu Huang, Shuiyang Xu,
et al., to identify how much Chinese women know and how they
react to HPV vaccination. The investigation was done for the
parents of students in the high school to evaluate their knowledge
of cervical cancer, HPV infection, and its vaccine through a pre-
tested questionnaire. A total of 1125 parents responded, of which
87.5% said that cervical cancer the most widespread genital cancer
and 78.67% said that HPV leads to cancer. Only 54.3% said that HPV
vaccination is available, and 35.6% said that they are sure when to
vaccinate their children. Of the samples, 4.4% had given the vaccine
to their daughters, and 35.4% were ready for vaccination. The
parents' knowledge level of cervical cancer was low regarding HPV
and its vaccination. Their Vaccine acceptance was also low. Hence
they recommended that awareness programs and education are
necessary to firm up the HPV vaccination program in China. 197)
A cross-sectional analysis was done by Lixia and Junyong, among
women in western China to study their knowledge and acceptability
of the HPV vaccine. Questionnaires were circulated among 1300
women, and 1109 women. completed it. Of those who completed,
28,85% had heard about HPV, and only 8.3% had correctly
answered all the questions on HPV. More than half of the women
(51.2%) said that they would be willing to be vaccinated against
HPV. The study.
concluded that although women lacked basic knowledge about
HPV, many werewilling to take the vaccine. Hence the researchers
recommend that efforts to educate. the public should be taken, 19

A study was conducted in Romania to evaluate the knowledge and attitude

on the HPV vaccine among parents by Septimiu Voidazan, Monica Tarcea,
Silviu-Horia Morariu, Adelina Grigore, and Minodora Dobreanu. It was done
in three schools. Of the 918 parents, 85.8% said they have listened to
information about HPV vaccination from specialized health care
professionals (39.1%) and through internet. browsing (42.9%). The fear of
side effects is the main reason for not wanting to vaccinate their child. The
study concluded that the acceptance of vaccination requires effective
implementation of educational strategies to parents and their children. 1997

A cross-sectional survey among the parents of school children was.

undertaken by Wei Wang, Yuanyuan Ma, et al to find out their awareness on
HPV vaccine. Of the 400 parents were covered by using cluster sampling,
22.63% had heard of HPV, and 10.2% had knowledge regarding HPV vaccine.
Only 40.8% of parents were ready to immunize their children, and 60%
supported promoting HPV vaccination as they believed that it could prevent
cervical cancer, genital warts, or anal cancer. They concluded that parental
awareness and willingness for vaccination were low though the general
attitude of parents towards HPV vaccine promotion was encouraging, 100

A study with the objective to evaluate the knowledge of cancer cervix

among women in Bangladesh and their readiness for HPV vaccination was
done by Islam JY, Khatun F. Alam A, Sultana F, Bhuivan A, Alam N, et al, with
2037 married women. The women were assessed on their knowledge of
cervical cancer and their willingness to get the HPV vaccination. Most of the
women stated that they had heard about cervical cancer. But, only a few
women (6.4% in urban and 4.4% in rural) reported that they have detailed
knowledge of the risk factors of cervical cancer and its prevention. Among
the urban women, those who were educated above secondary school and
those with high socioeconomic status had heard about HPV vaccination. The
readiness of the women to receive the HPV vaccine for themselves or their

daughters was high, 93.9% in urban and 99.4% in rural parents, for
themselves. In

urban area, 91.8% of parents and in rural area, 99.2% of parents were ready
tolearning environment to cultivate HPV vaccine champions". It was
a mixed method. study with three online synchronous focus groups,
including a pre and post-test and a six month follow-up. Most of the
parents were mothers. There was statistical disparity in the
knowledge of HPV and HPV vaccination among the pre and post-
test. The confidence of parents had increased through the
technology-mediated intervention. Those encouraged them to talk
liberally about HPV vaccination in person or online. The study
concluded that public media is a suitable means to empower
parents to address issues of vaccine uncertainty and
misinterpretation of HPV vaccine details
A controlled, quasi-experimental, mixed method study to evaluate a
technology-mediated HPV vaccine awareness intervention among
college-aged men and women was done by Heather M Brandt, et al.
A new, technology-mediated, social media based program was
evaluated to encourage HPV vaccination in the midst of college
students. A total of 58 students were randomized into two groups
receiving different interventions for cancer prevention- one on HPV
vaccination and the other on healthy weight control. There were
eight technology-mediated sessions with weekly e-mails and private
Facebook group posts. It was found that the knowledge of the
participants in the HPV vaccination intervention arm was more
compared with the control arm. The participants engaged with
interest and high satisfaction. The results suggested that college
students can be reached with educational interventions using the
social media platform to increase awareness of HPV vaccination.
1129
To understand the improvement of parents awareness, knowledge,
perception, and acceptability of HPV after a structured-educational
intervention, Mei Neni Sitaresmi, et al., conducted a study with 506
parents of primary school girls studying in 5th and 6th grade,
enrolled using proportional random sampling. The parents were
educated using a structured teaching program by a pediatric
resident on HPV and its vaccination. Of the parents 49.2% and
48.8% had heard about HPV infection and HPV vaccine before the
education. Noteworthy improvements were seen in parents
knowledge, awareness, and perceptions of HPV infection, cancer,
and HPV vaccination. The acceptability of HPV vaccination increased
from 74.3% to 87.4%. This study concluded that a planned
educational program might increase theA cross-sectional study was
done in Mysore, India by Abraham Degarege, et al, among parents
of adolescent girls living in a rural area. A questionnaire was
completed by 831 parents. It was found that 79.9% of the parents
were ready to vaccinate their daughters. Parents who believed the
vaccine was safe and had the support of family members had higher
odds (aOR 2.11) of willingness to vaccinate their daughters. Parents,
who thought that the risk of their daughters getting the infection
was low, had lower odds (aOR 0.52) of willingness to vaccinate their
daughters. The study concluded that health education to increase
the knowledge on the protection the vaccine offers and the
possibility of their daughters getting cervical cancer is important to
encourage vaccination,
A study to identify the factors that determine the attitudes and
beliefs towards HPV, cervical cancer and vaccine amongst the
parents of adolescents was done by Abraham Degarege, Karl Krupp,
et al., in Mysore, India. It was a cross- sectional study with 800
parents of school-going adolescent girls. It was found that Muslims
perceived that their daughters were at risk for HPV infection. The
parents" perception of the possibility of their daughters being
vulnerable to HPV infection (aOR: 0.94; 95% CI: 0.90, 0.98) or
cervical cancer (aOR: 0.95; 95% CI: 0.92, 0.99) decreased as the age
of the parents increased. As the parents' age increased, their odds
of thinking that the vaccine was effective increased (aOR: 1.03; 95%
CI: 1.003, 1.06). The study concluded that the age of the parents
and their religion were linked with the attitude of parents
concerning the danger of HPV and cervical cancer.
A study to explore the obstacles and facilitators of parental
acceptability of the HPV vaccine was undertaken by Purnima
Madhivanan, Tan Li, Vijaya Srinivas, Laura Marlow, Soumyadeep
Mukherjee and Karl Krupp, among 800 girls in Mysore.
Questionnaires were sent home through the girls to be filled in by
the parents. Data analysis showed that, of the parents, 71% were
ready to vaccinate their daughters. Adjusted odds of acceptance
were higher in samples with recommendations from parents, who
believed cancer to be a severe disease and understood that HPV
vaccine was safe. From the study it was concluded that
emphasis on the safety of immunization and involvement of
promotional education to
the extended family is highly recommended for the vaccination of
young girls. 1110
A study was performed in Thailand, by Phanida and Kanjana to
recognize the variables related with the receipt of HPV vaccination
amid the primary caregivers/parents. The study enrolled 331
parents of adolescent girls, and each one. completed a survey
designed to evaluate the demographic date, HPV vaccine
acceptability, awareness, and beliefs towards HPV and cervical
cancer. More than half had got information about HPV, and their
knowledge regarding HPV and cervical cancer was average.
Acceptance of the vaccine was related with the apparent
advantages of the vaccination (OR 1.49) and perceived susceptibility
(OR 1.42). They concluded that the parents beliefs play a vital role
in their vaccine reception. Education and vaccination campaigns can
be undertaken to impact the beliefs of parents and encourage
vaccination,
A cross-sectional study among 290 mothers of adolescent girl
students was conducted in Nigeria by B N Azuogu, et al. It was to
appraise the willingness of mothers to vaccinate their daughters
with HPV vaccine using a pre-tested self- administered
questionnaire. Data analysis was done using Epi Info™ version 7,
and it was found that the awareness of HPV was 42.8%. Though
89.1% were ready to vaccinate their girls, only 6.9% were
vaccinated. Reduced awareness and high price of the vaccine were
grounds for low vaccine uptake. The authors concluded that there is
an imperative call for education campaigns to increase awareness,
and HPV vaccination can be added to the national immunization
schedule to remove the financial constraints, (113)
A study to check the knowledge and vaccine uptake of HPV among
Hispanic fathers of adolescents was performed by Julie Kornfeld, et
al. Data was collected from 189 fathers, and most of them were
ready to vaccinate their kids (son- 87.5%, daughter 78.8%). Their
awareness of HPV was low and their knowledge varied. The study
concluded that culturally informed educational efforts were
necessary to increase informed decision-making about vaccinating
their children.
A study with the purpose of examining the factors owing to HPV
vaccine rejection despite the recommendations of the health care
provider was undertaken by Alexandra B Khodadadi, David T
Redden, and Isabel C Scarinci. It was a survey of mothers on their
sociodemographics data, knowledge and professed
danger of HPV infection, and thought to immunize their daughters.
Almost one-thirdof the mothers (35.3%) of the 317 mothers
interviewed said that they would be uncertain to vaccinate their
daughters even if the health care providers recommend it. The
study concluded that just a prescription by the doctor might not be
adequate to encourage mothers to vaccinate their children. 14
A population-based survey was performed in Sweden in 2007 to
investigate the attitudes towards HPV vaccination among parents of
adolescents between 12-15 years of age by Lisen A. Dahlstro M.
Trung N. Tran, Cecilia Lundholm, Cecilia Young, Karin Sundstro, and
Par Sparen. A total of 16,000 parents of girls and 4,000 parents of
boys were selected randomly. It was found that 76% of parents
were ready to immunize their kid if the vaccine was given free, and
63% were ready even if they had to pay for it. If parents knew about
HPV, they accepted vaccination even with a cost. Belief in vaccine
safety and efficacy strongly correlated with the willingness to
vaccinate. The study concluded that education to parents regarding
the safety of the vaccine and its efficacy is vital. 1115
The knowledge and awareness of HPV vaccine and the probable
acceptance of HPV vaccine among mothers having a teenage girl
were investigated by Yang Yu, et al., in China. Mothers of teenage
daughters (n=1850) were included in the cross-sectional survey. The
response rate was 85.30%, and 19.32% of mothers were aware of
HPV and its vaccination. Awareness varied with daughter's age,
mother's education, household income, and residence type. The
knowledge was inadequate and the mean score of 3.56 for 13. It
was found that housewives and. unemployed mothers had the
highest acceptability. Awareness and knowledge about HPV and
vaccination were low in Chinese woman. These findings can be used
to design appropriate health education programs for the target
population, (116)
A descriptive study to investigate the knowledge, outlook, and
perceptions of parents towards HPV vaccination in Nigeria was
done by Beatrice Ohareri, Abiola Olufunmilayo Adefolaju, and
Chiemerigo Anne Onyeneho. One hundred eighty-six parents were
enrolled. Most of the parents (98.9%) had adequate knowledge of
the HPV vaccine but demonstrated a negative attitude to the
vaccine,
This was due to the high cost (86%), level of education (81%), and
concern about the
adverse effects (80%). The study recommended that the barriers
causing negative
attitudes should be addressed to increase vaccine uptake, 1117)

A national immunization survey (2008-2012) in the United States

was undertaken by Vinay K. Cheruvu, et al., to spot the factors
related with parental reasons for "no intent" to vaccinate their
adolescent children with HPV vaccination. The results showed that
the major factors were mother's education, ethnicity,
recommendation by health care worker and age of the girl. The
study identified. subgroups of parents who had no plan to vaccinate
their children and strategies were developed to provide targeted
educational interventions to these parents,
The influences affecting the attitude of parents regarding HPV
vaccine were studied by Kate Lawless, et al., through an anonymous
questionnaire among 158 individuals to measure the HPV
knowledge, information sources, and attitude of parents. It was
found that 68.3% of parents had adequate knowledge, and parents
with less information were more towards consenting to vaccinate
than those who knew about the vaccine. The study recommended
that evidence-based factual information be shared with parents to
counter the negative media influence and ensure fully informed
evidence-based decision-making among the parents,
A study to determine vaccine reception among unvaccinated
adolescent boys and their parents to show a relationship between
the vaccine acceptance with their knowledge, and individual
experience was performed by Shalinee Khurana, Heather L. Sipsma,
and Rachel N Caskey. Of the 154 adolescents, only 16% were ready
to accept the vaccine, and of the 121 parents enrolled, 34% were all
set to vaccinate their sons. The study concluded that as vaccine
acceptance was low, it is important to educate parents and
adolescents on the advantages and efficacy of HPV vaccines against
genital warts and genital cancers, 1120

The attitude towards and awareness about HPV and HPV

vaccination in parents of teen boys was studied in the United
Kingdom by Susan Mary Sherman and Emma Nailer using a self-
reported questionnaire. Participants were 186 parents of teenage
boys. It was found that only 50% of the parents have heard about
HPV and its vaccination. Of those who had some previous
information, their knowledge on the health effects of men infected
with HPV was inadequate compared with their knowledge about
the female outcomes. The parents who knew about HPV vaccines
were in favor of vaccinating their boys compared to those who did
not know about the vaccine. Most parents said that boys also must
be vaccinated, 1621
A study to find the influence of the sources of details on the
parental attitudes on HPV vaccine uptake in adolescents was
undertaken by Natasha Underwood, Lisa Gargano, Samantha
Jacobs, et al. It was a 3-arm randomized controlled trial with 360
parents of adolescents studying in high school. Data collection was
done through phone and an online survey. Almost 53% of the
parents said that their kids had got a minimum of a single dose of
HPV vaccination. The parents stated that the top source of
information was from medical professionals (80%) and television
(64%). There was a relationship between the source of information
and parental attitudes. The findings highlighted the significance of
the origin of information and parental attitudes, 11221
2.4 Section D: Effect of educational interventions on the knowledge
and attitude of parents regarding HPV vaccination
.
A systematic review to evaluate and summarize the evidence for
educational activities to improve HPV vaccination acceptance was
performed by Linda Y. Fu, et al. There were 33 HPV studies
identified with educational interventions in which seven tested the
effectiveness of interventions with parents. With young adults it
was eight studies and 18 studies on comparison between
adolescents, young adults, and their parents. Most of the studies
required the participants to be literate. The study did not identify
any specific educational intervention for widespread
implementation and recommended further studies to design and
test culturally competent educational interventions, 1121
A systematic review of the studies on the interventions undertaken
to increase HPV vaccine coverage to evaluate the effects of the
interventions were done by Edison J Mavundza, et al. as the HPV
vaccine coverage remains low despite the availability of effective,
safe vaccines. Thirty-five studies fulfilling the inclusion criteria were
reviewed from "Cochrane Central Register of controlled trials,
Pubmed. Web of Science, Scopus, and WHO International Clinical
Trials Registry Platform".. Review results showed that narrative
education, training, feedback, and multicomponent interventions
are a few of the interventions which improved vaccine coverage
and were conducted primarily in high-income countries. The need
for similar studies in the low and middle-income countries was
stressed in the study, 1124
A systematic review on the outcome of school-based educational
programs in the adolescent population on HPV vaccine acceptance
was conducted by Terri Flood, Iseult M Wilson, Gillian Pure, Marian
McLaughlin, and Ciara M Hughes, Randomized Controlled Trials and
Quasi-experimental studies from 2007 to 2019 were searched, and
15 studies were included for analysis. The study findings confirmed
a statistically important enhancement in a minimum of one key
outcome, such as knowledge, attitude, or vaccination. The text was
mainly focused on cervical cancer and a few on cancers in men
caused by HPV. The researchers concluded that a mixed-gender
educational program should be established for teenagers. (125)
A study to assess the effects of HPV and HPV vaccine education
program for parents, health care workers, and school employees
was done by Paul L. et al. 376 parents, 118 health care workers and
456 school employees was enrolled in the study and participated in
the class, and filled-up self-administered surveys. The results
showed that the samples had low HPV and HPV vaccine knowledge
before the program. The educational program improved the self-
rated knowledge among all the participants. After the intervention,
most of the participants believed that HPV and HPV vaccine
education is important and middle schools are appropriate venues
for this intervention. Educational programs are a simple but
efficient approach for maximizing HPV vaccination and gaining
support for school-based vaccination. 1126)
The impact of school-based education regarding cervical cancer on
perceptions about HPV vaccination among adolescent girls at Hong
Kong Chinese was studied by Tracy TC Kwan, et al. A total of 953
adolescent girls participated in a tailored educational program. The
awareness, attitude, and apparent social norms regarding HPV
vaccination and their intent to be immunized were measured
through questionnaires before and after the education. The
participants knowledge and attitude improved after participating in
the program. They concluded that the educational program had a
constructive impact on the girls opinion towards HPV vaccination
and their readiness to be vaccinated. A possible way to address the
educational requirements of adolescents is school-based education
programs. Educating the families can have a positive impact too,
11277
A technology-mediated educational program for parents was
evaluated through a study by Beth Sundstrom, et al. This study
tested a "collaborative onlineawareness, knowledge, and
perception of parents towards HPV vaccination and impact the
acceptability of the vaccine, (130
A school-based education program regarding HPV and its vaccine
was given by Chun-Rong Liu, et al. They assessed its effectiveness
on the knowledge and attitude of junior middle school children,
who were selected by convenient sampling. All participants were
administered a self-administered questionnaire followed by power
point oriented health education for the intervention group. They
also completed a post-education questionnaire and follow-up
survey after one year. A total of 1675 students participated in the
study and 34.3% had previous information about cervical
cancer/genital warts, and only 15.1% had ever heard about HPV.
But 55.2% of students were willing to be vaccinated even before
the intervention, and after the intervention, 88.4% were willing to
be vaccinated. However, it decreased significantly after one year.
The study concluded that the baseline knowledge among students
HPV, its vaccine, and cancer was less. Education is effective in
raising the understanding of HPV and readiness to vaccinate.
Frequent health education at short intervals should be given, 11311
A multi-center study to identify the effectiveness of a school-based
educational program on HPV and HPV vaccination on the
knowledge and acceptance of vaccination among Chinese kids who
were 13-14 years of age was undertaken by Xi Zhang, et al. After
pre-test, the adolescents in the intervention group were given a 45-
minute talk on HPV and its vaccination. They completed a post-talk
questionnaire and after one year, the post-talk questionnaire was
given again. The initial knowledge was very poor (12.6%). About
15.7% of students had previous information HPV vaccines. Still, the
knowledge was notably more in students educated in the
intervention group. Students with higher knowledge were more
willing to be vaccinated. The study concluded that knowledge and
awareness are generally deficient in this population, and
incorporating HPV health education in the school program can
increase knowledge and vaccine uptake. 1132
A multi-center, study aimed at understanding the effect of
educational program on HPV knowledge and attitude regarding HPV
vaccines in health care workers (HCW) in western China was
performed by Hui Chen, et al. A total of 1448 health care workers
were enrolled and attended the educational lectures. In generalto
them. This study stressed the need for detailed evidence-based
information on HPV vaccination, 10
A study to understand the health beliefs of African-American
parents and their daughters towards HPV vaccine acceptance was
undertaken by Kayoll V Galbraith-Gyan, et al., with the health belief
model as a guiding framework. A total of 30 Afro- American parents
and their daughters were interviewed personally, and the data was
analyzed using principles of "grounded theory, theoretical sampling,
and constant comparison analysis". Mothers and their daughters
perceive that the HPV vaccine is advantageous in defending against
warts and cancer cervix. Parents emphasized on the protection that
the vaccine grants against genital warts. This study concluded that
to develop suitable HPV vaccine initiatives, a good understanding of
the health beliefs that promote vaccine acceptance is essential, 100
A cross-sectional study was conducted by Maria Grandhal, et al., in
Thailand to identify parents knowledge, viewpoint, and reception of
HPV vaccination and associate them with their socio-demographics
and religious values. This was a school-based survey where the
parents of daughters completed a questionnaire. A total of 359
parents participated, and 301 samples were analyzed. The results
demonstrated that the awareness of HPV and HPV vaccination was
definitely related to the HPV and cervical cancer knowledge. The
knowledge was not significantly related to the barriers. Parents
with religious beliefs were more favorable to HPV vaccination. The
overall acceptance of vaccines was high. (106)
In India, at Mysore, a study to compare the attitude of parents and
their idea about cervical cancer, human papillomavirus, and HPV
vaccine among the urban and rural vicinity was conducted by
Abraham Degarege, et al. A total of 1609 parents of school going
adolescent girls, 778 from an urban area and 831 from a rural area,
were included in the study where the parents completed a self-
administered questionnaire. It was found that 73.6% of parents had
not heard about HPV, and 62.7% never knew that their kids could
be infected by HPV or get cervical cancer (64.1%) in the future. The
urban parents believed that HPV infection can lead to severe
outcomes (aOR 2.69). The study concluded that parents living in
rural area may be hesitant to advocate immunization for their
daughters,