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Cited by 34Cervical Cancer and HPV ResearchVaccine Coverage and HesitancyWomen's cancer prevention and management

Human Papillomavirus Vaccine Acceptability among Parents of Adolescent Girls in a Rural Area, Mysore, India

Open access
Degarege, Abraham, Krupp, Karl, Fennie, Kristopher, Srinivas, Vijaya, Li, Tan, Stephens, Dionne P., Marlow, Laura A.V., Arun, Anjali +1 more·2018·Journal of Pediatric and Adolescent Gynecology
DOI 10.1016/j.jpag.2018.07.008PMC PMC7679173
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Abstract

Study objective The purpose of this study was to examine factors predicting human papillomavirus (HPV) vaccine acceptability among parents of adolescent girls in a rural area in Mysore district, India. Design Cross-sectional. Setting Mysore, India. Participants Parents of school-going adolescent girls. Interventions Parents completed a validated self-administered questionnaire. Main outcome measures Parental willingness to vaccinate their daughters with HPV vaccine. Results Of the 831 parents who participated in this study, 664 (79.9%) were willing to vaccinate their daughter with HPV vaccine sometime soon if they were invited to receive it. Higher odds of parental willingness to vaccinate their daughters with HPV vaccine was observed among those who believed that HPV vaccine is safe (adjusted odds ratio [aOR], 2.11; 95% confidence interval [CI], 1.01-4.45); their daughter might become sexually active (aOR, 1.84; 95% CI, 1.08-3.13); they have support of other family members to vaccinate their daughter (aOR, 2.86; 95% CI, 1.47-5.57); and that HPV infection causes severe health problems (aOR, 1.64; 95% CI, 1.04-2.57). In contrast, parents who believed that there is low risk that their daughter will get cervical cancer (aOR, 0.52; 95% CI, 0.29-0.95); that the family will disapprove of getting their daughter vaccinated (aOR, 0.45; 95% CI, 0.22-0.76); that the injection might cause pain (aOR, 0.53; 95% CI, 0.31-0.89), and were older-age parents (aOR, 0.96; 95% CI, 0.93-0.99) had lower odds of willingness to vaccinate daughters with HPV vaccine. Conclusion Acceptance of HPV vaccination for daughters was high among rural parents in Mysore, India. However, health education to reduce the belief that injection is painful and that daughters are at low risk to get cervical cancer is important to further improve parental HPV vaccine acceptability in Mysore. Public health education should target older-aged parents and extended family members.

AI snapshot

Written from the paper’s full text.

TL;DR

In a cross-sectional survey of 831 parents of adolescent girls in rural Mysore, India, 79.9% were willing to vaccinate their daughters with HPV vaccine. Willingness was higher with beliefs that the vaccine is safe, HPV infection is severe, the daughter may become sexually active, and family supports vaccination, while older parental age and beliefs about low cervical cancer risk, family disapproval, and injection pain lowered willingness.

Key findings

  • Of 831 parents, 79.9% were willing to vaccinate their daughter with HPV vaccine sometime soon if invited; 30.2% said “probably yes” and 49.7% said “definitely yes.”
  • Higher adjusted odds of willingness were associated with believing the HPV vaccine is safe (aOR 2.11; 95% CI 1.01–4.45), daughter may become sexually active (aOR 1.84; 95% CI 1.08–3.13), support from other family members (aOR 2.86; 95% CI 1.47–5.57), and HPV infection causes severe health problems (aOR 1.64; 95% CI 1.04–2.57).
  • Lower adjusted odds of willingness were associated with believing the daughter is at low risk of cervical cancer (aOR 0.52; 95% CI 0.29–0.95), family disapproval of vaccination (aOR 0.45; 95% CI 0.22–0.76), injection may cause pain (aOR 0.53; 95% CI 0.31–0.89), and older parental age (aOR 0.96; 95% CI 0.93–0.99).
  • Parents with 1–10 years of education had higher odds of willingness than parents with no formal education (aOR 1.92; 95% CI 1.13–3.26).

Methods

  • Cross-sectional survey conducted between September and October 2011 among parents of adolescent girls ages 11–15 in 7th–10th grades in 11 schools in rural Mysore Taluk, Karnataka, India.
  • Of 1,725 eligible girls, 850 parents were randomly selected; 831 parents completed and returned a validated self-administered questionnaire in Kannada.
  • Analysis used chi-square tests and multiple logistic regression with Generalized Estimating Equations to account for school clustering; multiple imputation by chained equations was used for missing values.

Limitations

  • Stated: only parents of school-going adolescent girls were included, limiting generalizability to parents without school-going children in that age group.
  • Stated: findings may not generalize to other regions of India or other religions because the sample was almost entirely Hindu and only eight parents were Muslim.
  • Stated: self-reported data may have information bias, especially if illiterate parents received help; providing basic HPV/cervical cancer/vaccine information may have overestimated associations; missing data were imputed; the study assessed willingness, not actual vaccination; and the 2011 data may no longer reflect current beliefs.
  • Evident from design: the cross-sectional design cannot establish causality between beliefs/attitudes and vaccine acceptability.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1016/j.jpag.2018.07.008

Cites

33 of 33 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

5 of 24 cited sources checked · 0 supported · 0 flagged · accuracy not yet measured

  • Findingown data
    § Abstract

    Higher odds of parental willingness to vaccinate their daughters with HPV vaccine was observed among those who believed that HPV vaccine is safe (aOR 2.11; 95% CI: 1.01, 4.45).

    “Higher odds of parental willingness to vaccinate their daughters with HPV vaccine was observed among those who believed that HPV vaccine is safe (Adjusted Odds Ratio [aOR] 2.11;95% CI:1.01, 4.45)”
    Quote in the paperSubstantial claim
  • Findingown data
    § Abstract

    Parents who believed that the injection may cause pain had lower odds of willingness to vaccinate daughters with HPV vaccine (aOR 0.53, 95% CI: 0.31, 0.89).

    “the injection may cause pain(aOR0.53, 95%CI:0.31,0.89)”
    Quote in the paperSubstantial claim
  • Findingown data
    § Abstract

    Higher odds of parental willingness to vaccinate their daughters with HPV vaccine was observed among those who believed their daughter may become sexually active (aOR 1.84, 95% CI: 1.08, 3.13).

    “daughter may become sexually active (aOR1.84, 95%CI:1.08, 3.13)”
    Quote in the paperSubstantial claim
  • Findingown data
    § Abstract

    Of the 831 parents who participated, 79.9% were willing to vaccinate their daughter with HPV vaccine sometime soon if they were invited to receive it.

    “Of the 831 parents participated in this study, 79.9% were willing to vaccinate their daughter with HPV vaccine sometime soon if they were invited to receive it.”
    • Also stated in: § Results · plain
      “Of the 831 parents, 79.9% (Yes probably=30.2%, Yes definitely=49.7%) were willing to vaccinate their daughter with HPV vaccine sometime soon if they were offered the vaccine for their daughter (Table 1).”
    Quote in the paperSubstantial claim
  • Findingown data
    § Results

    Willingness to vaccinate was lower among parents who believed their daughter was at low risk to get cervical cancer (aOR 0.52, 95% CI 0.29-0.95).

    “The odds were particularly lower among parents who believed that their daughter was at low risk to get cervical cancer (aOR 0.52, 95%CI: 0.29, 0.95); the family may disapprove of getting their daughter vaccinated (aOR 0.45, 95%CI: 0.22, 0.76) and the injection may cause pain (aOR 0.53, 95%CI: 0.31, 0.89).”
    Quote in the paperSubstantial claim
  • May combine two claims. 7
  • Classified as probably not a substantial claim. 11

  • May combine two claims.

    Interpretationreasoning
    § Discussion

    HPV vaccine acceptance in this rural Mysore population was higher than reported among parents in other regions of India (46-74%) and other south Asian countries (26.5-84.0%).

    “There was a higher rate of HPV vaccine acceptance in this population as compared to that reported among parents in the other regions of India (Range: 46% to 74%) 13,14,22 and other countries in south Asia (Range: 26.5% to 84.0%).23-26”
    Quote in the paperSubstantial claim1 of 7 sources checked
    • cites [13] Basu, 2011, Acceptability of human papillomavirus vaccine among the urban, affluent and educated parents of young girls residing in Kolkata, Eastern India, J Obstet Gynaecol source
    • cites [14] Madhivanan, 2014, Human papillomavirus vaccine acceptability among parents of adolescent girls: obstacles and challenges in Mysore, India, Prev Med source
    • cites [22] Montgomery, 2015, Knowledge and acceptability of human papillomavirus vaccination and cervical cancer screening among women in Karnataka, India, J Cancer Educ source
    • cites [23] Sam, 2009, Maternal acceptance of human papillomavirus vaccine in Malaysia, J Adolesc Health source
    • cites [24] Charakorn, 2011, Knowledge of Pap smear, HPV and the HPV vaccine and the acceptability of the HPV vaccine by Thai women, Asia Pac J Clin Oncol source
    • cites [25] Yu, 2016, Human papillomavirus infection and vaccination: awareness and knowledge of HPV and acceptability of HPV vaccine among mothers of teenage daughters in Weihai, Shandong, China, PLoS One source

      The Discussion reports 26.5% potential HPV vaccine acceptability among mothers in Weihai, Shandong, China, supporting the lower endpoint of the cited range. But China is not in South Asia, so this source does not support classifying its population as from a South Asian country. The other citations may account for the rest of the range. (LLM, conf=0.88)

      Experimental — accuracy not yet measured
    • cites [26] Wang, 2015, Acceptability of human papillomavirus vaccine among parents of junior middle school students in Jinan, China, Vaccine source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation
    § Discussion

    In Senegal, awareness about HPV was greater among adolescents and parents living in rural areas than among urban ones.

    “The level of awareness about HPV in Senegal was also greater among adolescents and parents who were living in rural area than the urban ones. 27”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [27] Massey, 2017, Human papillomavirus (HPV) awareness and vaccine receptivity among Senegalese adolescents, Trop Med Int Health source

      The Results (Predictors of willingness to get HPV vaccine) report that students who spent most of their lives in rural areas had higher odds of having heard of HPV than students who grew up in urban areas. The study does not report the same rural–urban comparison for parents; its Discussion describes parents as stakeholders in sharing vaccine information, not as surveyed respondents. The residence measure also concerns where students grew up, rather than necessarily where they currently lived. (LLM, conf=0.88)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation
    § Introduction

    Uptake of HPV vaccination in general has been low in India due to misperceptions about HPV infection, cervical cancer and HPV vaccine, and due to cultural reasons.

    “However, uptake of HPV vaccination in general has been low due to misperceptions about HPV infection, cervical cancer and HPV vaccine, and due to cultural reasons in India.”
    Quote in the paperSubstantial claim1 of 5 sources checked
    • cites [7] Chatterjee, 2016, HPV and cervical cancer epidemiology - current status of HPV vaccination in India, Asian Pac J Cancer Prev source
    • cites [11] Madhivanan, 2009, Attitudes toward HPV vaccination among parents of adolescent girls in Mysore, India, Vaccine source
    • cites [12] Paul, 2014, Acceptability of HPV vaccine implementation among parents in India, Health Care Women Int source

      The Discussion (page unavailable) reports limited knowledge of HPV and cervical cancer and says concerns about vaccine side effects may foster misinformation and negative attitudes. But the study examined parental attitudes before the vaccine was available in its study area; it does not establish that vaccination uptake was generally low in India or that misperceptions and cultural reasons caused low uptake. (LLM, conf=0.86)

      Experimental — accuracy not yet measured
    • cites [13] Basu, 2011, Acceptability of human papillomavirus vaccine among the urban, affluent and educated parents of young girls residing in Kolkata, Eastern India, J Obstet Gynaecol source
    • cites [14] Madhivanan, 2014, Human papillomavirus vaccine acceptability among parents of adolescent girls: obstacles and challenges in Mysore, India, Prev Med source

  • May combine two claims.

    Premisecitation
    § Introduction

    Much of the research to date about HPV vaccine acceptability in India has been limited to urban areas, with very limited information available from rural India where 60% of the Indian population resides.

    “Much of the research to date about HPV vaccine acceptability in India has been limited to urban areas with very limited information being available from rural India where 60% of the Indian population resides.”
    Quote in the paperSubstantial claim1 of 4 sources checked
    • cites [11] Madhivanan, 2009, Attitudes toward HPV vaccination among parents of adolescent girls in Mysore, India, Vaccine source
    • cites [12] Paul, 2014, Acceptability of HPV vaccine implementation among parents in India, Health Care Women Int source

      The paper's introductory passage (labeled Abstract in our copy; page unavailable) says relatively little HPV vaccine acceptability research had been done in India and describes this study as taking place in a peri-rural area. It does not establish that most prior Indian research was urban or state that 60% of India's population resides in rural areas. Its separate reference to nearly 60% concerns HPV-related high-grade lesions, not population residence. (LLM, conf=0.84)

      Experimental — accuracy not yet measured
    • cites [13] Basu, 2011, Acceptability of human papillomavirus vaccine among the urban, affluent and educated parents of young girls residing in Kolkata, Eastern India, J Obstet Gynaecol source
    • cites [14] Madhivanan, 2014, Human papillomavirus vaccine acceptability among parents of adolescent girls: obstacles and challenges in Mysore, India, Prev Med source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation
    § Discussion

    According to the conceptual framework proposed by Fernandez, the nature of the environment will further modify the influence of parents' willingness to vaccinate their daughter on actual HPV vaccine uptake.

    “According to the conceptual framework proposed by Fernandez which guided this study, the nature of the environment will further modify the influence of parent’s willingness to vaccinate daughter with HPV vaccine on the actual uptake of HPV vaccine.19”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [19] Fernandez, 2010, Integrating clinical, community, and policy perspectives on human papillomavirus vaccination, Annu Rev Public Health source

      The Conceptual Framework/Logic Model section proposes that willingness to vaccinate influences HPV vaccination and that environmental factors influence willingness. It does not say that the environment modifies the effect of willingness on actual uptake; it also cautions that much of the evidence concerns acceptability rather than uptake. No page number is available in our copy. (LLM, conf=0.86)

      Experimental — accuracy not yet measured

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given
    § Methods

    One private and ten government schools were selected from a group of 43 schools available in the study area based on probability proportionate-to-size sampling.

    “One private and ten government schools were selected from a group of 43 schools available in the study area based on probability proportionate-to-size sampling.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data
    § Methods

    Missing values for some items were estimated using multiple imputation (using chained equation) based on 20 iterations before fitting the GEE.

    “As there were missing values for some of the items (Missing range: 0.48 to 3.61%) included in the regression model, a multiple imputation method (using chained equation) based on 20 iterations was used to estimate the missing values before fitting the GEE.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given
    § Methods

    Factors included in the regression model were checked for multicollinearity.

    “While fitting the regression models, factors that were included in the regression model were checked for multicollinearity.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data
    § Methods

    The study was conducted after review and approval by the Institutional Review Boards at Florida International University and Public Health Research Institute of India, and parents provided written informed consent.

    “This study was conducted after review and approval by the Institutional Review Boards at Florida International University and Public Health Research Institute of India. In addition, permission to conduct the study was obtained from the Block Education officer and school administrators. Parents participated in the study after they provided written informed consent.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductreasoning
    § Methods

    To account for potential clustering of HPV acceptance by the school that the daughters attended, analysis was performed using Generalized Estimating Equations (GEE).

    “To account for potential clustering of HPV acceptance by the school that the daughters attended, analysis was performed using the Generalized Estimating Equations (GEE) in Stata using the xtgee command.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Study design and conductcitation
    § Methods

    The questionnaire was validated in Kannada (the local language in the study area) and had been used in another study before it was used in this study.

    “The questionnaire was validated in Kannada (local language in the study area) and has been used in another study14 before it was used in this study.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [14] Madhivanan, 2014, Human papillomavirus vaccine acceptability among parents of adolescent girls: obstacles and challenges in Mysore, India, Prev Med source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data
    § Methods

    Most parents (97.8%) who received the questionnaire completed the questionnaire and returned it along with their signed consent form.

    “Most parents (97.8%) who received the questionnaire completed the questionnaire and returned it along with their signed consent form.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

    Interpretationreasoning
    § Discussion

    The time delay between the conduct and presentation of the study results may influence the nature of policy measures that can be designed to increase HPV vaccine acceptability among rural parents in Mysore, India.

    “There may have been changes in the beliefs and attitudes of parents regarding HPV infection, cervical cancer and HPV vaccine in the last seven years. This time delay in the conduct and the presentation of the study results may influence the nature of policy measures that can be designed to increase HPV vaccine acceptability among rural parents in Mysore, India.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data
    § Discussion

    Only eight parents in the study were Muslims, which may limit generalizability of the results to other religions since the majority of the sample belonged to Hindu religion.

    “The fact that only eight parents were Muslims in the current study may also limit generalizability of the results to other religions since the majority of the sample belonged to Hindu religion.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Most Muslims in Mysore district are concentrated in urban areas with very small percent living in rural regions.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation
    § Discussion

    A previous report from Indonesia showed lower HPV vaccine acceptance among older parents compared to younger ones.

    “This finding is consistent with a previous report from Indonesia, which showed lower HPV vaccine acceptance among older age parents compared to the younger ones.34”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [34] Jaspers, 2011, Parental acceptance of human papillomavirus (HPV) vaccination in Indonesia: a cross-sectional study, Vaccine source

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductreasoning
    § Discussion

    Because data were self-reported, some parents, especially illiterate ones, may have received support from friends or extended family while responding to some questions, which may have caused information bias.

    “In addition, as the data were self-reported, some parents, especially the illiterate ones, may have received support from friends or extended family members while responding to some questions which may have caused information bias.”
    Quote in the paperNot a substantial claim
16 of 16

  • The authors state this as an assumption.

    Items with a response of 'Don't know' were assumed to be ordinally neutral.

    “Items that has a response of ‘Don’t know’ were assumed to be ordinally neutral.20”

  • The paper relies on this without support.

    Public health education can reduce parents’ false perception of low risk of cervical cancer and fear of pain with injection, thereby improving HPV vaccine acceptability.

    “However, public health education programs to reduce the false perception of low risk of getting cervical cancer, and fear of pain with injection will be important issues to focus among parents in Karnataka to reduce cervical cancer rates and further improve parental acceptability of HPV vaccine in the district.”

  • The paper relies on this without support.

    Missing data were missing at random, so multiple imputation yields valid estimates.

    “However, the multiple imputation method used to predict the missing values showed results that were comparable to those obtained with analysis with complete dataset after removing the missing values.”

  • The paper relies on this without support.

    This study is one of few studies addressing public health issues among rural Indians.

    “In conclusion, this study is one of few studies that addresses public health issues among rural Indians.”

  • The paper relies on this without support.

    The rural population in this region has not been studied adequately.

    “A strength of this study was the focus on rural population—a population that has not been studied adequately.”

  • The paper relies on this without support.

    Most Muslims in Mysore district are concentrated in urban areas with very small percent living in rural regions.

    “Most of the Muslims in Mysore districts are concentrated in urban areas with very small percent living in rural regions.”
6 of 6

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • Demographic characteristics such as age, gender, educational level, place of residence, socioeconomic status, and religion were found to influence both HPV awareness and vaccine acceptance.

    “Demographic characteristics such as age, gender, educational level, place of residence, socioeconomic status, and religion were found to influence both HPV awareness and vaccine acceptance18,27,28,30,36.”

    From Barriers to HPV vaccination among adolescent girls in India: A scoping review (2026) · cites this paper as [18]

    The Discussion (page not available in our copy) identifies parental education and age as factors associated with vaccine acceptance. The Results show no clear association of acceptance with gender or religion, and the study does not establish that the listed demographics influence HPV awareness; it also does not compare places of residence or report socioeconomic status as such. (LLM, conf=0.88)

    Experimental — accuracy not yet measured

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Eligible-girl count exceeds the stated per-school maximum

    Minor

    Even if all 11 schools had 137 eligible students, they would have at most 1,507-not the reported 1,725 eligible girls.

    Reported 1725 · recomputed 1507

  • Family-disapproval confidence interval differs from Table 3

    Minor

    The abstract and results give 0.22 as the lower 95% confidence limit, while Table 3 gives 0.26 for the same adjusted odds ratio.

2 of 2

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Authors
Degarege, A., Krupp, K., Fennie, K., Srinivas, V., Li, T., Stephens, D. P., Marlow, L. A. V., Arun, A., & Madhivanan, P.
Affiliations
  • Florida International University (US)
  • Public Health Research Institute Of India (IN)
  • University College London (GB)
Corresponding author
Madhivanan, Purnima
ORCID
Venue
Journal of Pediatric and Adolescent Gynecology
Publisher
Elsevier BV
Published
2018-12
Volume
31
Issue
6
Pages
583-591
ISSN
  • 0932-8610 (ISSN-L)
  • 1083-3188
DOI
10.1016/j.jpag.2018.07.008
PMC
PMC7679173
OpenAlex
W2884042051
Cited by
34
References
32
Citations by year
2026: 6 · 2025: 10 · 2024: 7 · 2023: 4 · 2022: 2 · 2020: 2 · 2019: 2 · 2018: 1
FWCI
0.85
Type
journal article
Language
en
Open access
Licence
Locations
  • Journal of Pediatric and Adolescent Gynecology (publishedVersion)
  • PubMed (publishedVersion)
  • PubMed Central (submittedVersion)
  • UCL Discovery (University College London) (submittedVersion)
  • Research Portal (King's College London) (submittedVersion)
Funders
  • Merck
  • Florida International University
  • National Heart, Lung, and Blood Institute
  • Fogarty International Center (D43TW010540)
Topics
  • Health Sciences › Medicine › Epidemiology › Cervical Cancer and HPV Research
  • Social Sciences › Health › Vaccine Coverage and Hesitancy
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Women's cancer prevention and management
Keywords
adolescent girls, cervical cancer prevention, vaccine safety beliefs, family support, rural parents, health education
MeSH terms
Adolescent, Adult, Uterine Cervical Neoplasms, Cross-Sectional Studies, Female, Humans, India, Health Knowledge, Attitudes, Practice, Middle Aged, Nuclear Family, Parents, Patient Acceptance of Health Care, Surveys and Questionnaires, Rural Population, Students, Vaccination, Odds Ratio, Papillomavirus Infections, Papillomavirus Vaccines

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