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Cited by 29Cervical Cancer and HPV ResearchVaccine Coverage and HesitancyWomen's cancer prevention and management

An integrative behavior theory derived model to assess factors affecting HPV vaccine acceptance using structural equation modeling

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Degarege, Abraham, Krupp, Karl, Fennie, Kristopher, Srinivas, Vijaya, Li, Tan, Stephens, Dionne P., Madhivanan, Purnima·2019·Vaccine
DOI 10.1016/j.vaccine.2019.01.012PMC PMC6351189
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Abstract

The study examined factors that affect parental intention-to-vaccinate adolescent daughters with HPV vaccine in Mysore district, India. A cross-sectional study was conducted among 1609 parents of adolescent girls attending schools in Mysore District between February 2010 and October 2011. A validated questionnaire was used to assess parental attitudes, beliefs related with HPV infection, cervical cancer, HPV vaccine and vaccination in general. Structural equation modeling was used to estimate parameters and assess whether a model based on the integrative behavior theory would fit the current data. More than two-thirds (78.0%) of parents would accept vaccinating their daughters with HPV vaccine. Intention to HPV vaccination significantly increased with increase in the perception of parents about the benefits (standardized regression coefficient (β) = 0.39) or sources of information about HPV vaccine (β = 0.24), but intention decreased significantly with an increase in the perception about barriers to HPV vaccination β = -0.44). The effect of beliefs about severity of HPV infection or cervical cancer (β = 0.20), and beliefs about benefits (β = 0.20) or barriers (β = -0.25) to vaccination in general on intention to HPV vaccination were significantly mediated by parental attitudes and source of information about the vaccine. Geographical location significantly moderated the awareness about HPV on beliefs about severity of HPV infection or cervical cancer (β = 0.33), and the effect of religion on norms related to HPV vaccination (β = 0.19). Fit of the model to the data was acceptable. This study identified modifiable parental attitudes about HPV vaccine and beliefs related with HPV infection, cervical cancer and vaccination, which predicted parental intention-to-vaccinate their daughters with HPV vaccine in India. Health education interventions tailored to counter parental negative attitudes and beliefs about HPV vaccine and vaccination in general would be important for the community to promote HPV vaccination.

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  • These misconceptions were especially prevalent in conservative or rural settings, where this was considered a stigma.

    “These misconceptions were especially prevalent in conservative or rural settings, where this was considered a stigma36,37.”

    From Barriers to HPV vaccination among adolescent girls in India: A scoping review (2026) · cites this paper as [36]

    The Introduction discusses misconceptions about HPV and its vaccine, and the Discussion reports that urban–rural residence moderated some parental beliefs. It does not say misconceptions were especially prevalent in rural or conservative settings or describe them as a stigma. The Discussion instead reports higher vaccination intention among rural than urban parents; page numbers were not available in our copy. (LLM, conf=0.82)

    Experimental — accuracy not yet measured

  • Community-level factors, including stigma, cultural norms, and religious beliefs, often reinforced vaccine hesitancy, though engagement with local leaders and culturally tailored interventions showed promise.

    “Community-level factors, including stigma, cultural norms, and religious beliefs, often reinforced vaccine hesitancy, though engagement with local leaders and culturally tailored interventions showed promise 28,30,34,36.”

    From Barriers to HPV vaccination among adolescent girls in India: A scoping review (2026) · cites this paper as [36]

    The Results and Discussion (page numbers unavailable) link religion and cultural practices to parental beliefs about HPV vaccination. The Introduction recommends adapting education programs to local culture and religion, but the paper does not report that such interventions were tested or showed promise. It does not address stigma or engagement with local leaders. (LLM, conf=0.87)

    Experimental — accuracy not yet measured

  • Many respondents, especially mothers, were uncomfortable with their daughters receiving a vaccine against a sexually transmitted disease, frequently attributing this to ethical issues and the belief that it encourages immorality.

    “Many respondents, especially mothers, said they were uncomfortable with their daughters receiving a vaccine against a sexually transmitted disease, frequently attributing this to ethical issues and the belief that it encourages immorality36,37,45.”

    From Barriers to HPV vaccination among adolescent girls in India: A scoping review (2026) · cites this paper as [36]

    The Introduction (page unavailable) reports that parental beliefs that HPV vaccination could promote sexual promiscuity were associated with lower intention to vaccinate daughters. It does not establish that many respondents—especially mothers—said they were uncomfortable because the vaccine targets a sexually transmitted disease, or that they frequently cited ethical issues. (LLM, conf=0.85)

    Experimental — accuracy not yet measured

  • Religion was another factor, with some communities expressing stronger resistance due to their religious norms or misinformation within their social circles.

    “Religion was also found to be another factor, with some communities expressing stronger resistance due to their religious norms or misinformation within their social circles36,42.”

    From Barriers to HPV vaccination among adolescent girls in India: A scoping review (2026) · cites this paper as [36]

    The Results section (page unavailable) finds that religion was associated with vaccination-related norms: Muslim parents were less likely than non-Muslim parents to expect others to recommend HPV vaccination. It does not establish that religious norms caused stronger resistance, or that misinformation within social circles did so; Muslim parents were also less likely to hold negative beliefs about vaccination. (LLM, conf=0.86)

    Experimental — accuracy not yet measured

  • Girls from urban and higher socioeconomic backgrounds were more likely to have heard of HPV and the vaccine, whereas those from rural or tribal areas had lower awareness and greater scepticism.

    “Girls from urban and higher socioeconomic backgrounds were more likely to have heard of HPV and the vaccine, whereas those from rural or tribal areas were found to have lower awareness and greater scepticism31,32,36.”

    From Barriers to HPV vaccination among adolescent girls in India: A scoping review (2026) · cites this paper as [36]

    The Discussion reports that urban–rural residence moderated the relationship between parents’ HPV awareness and their vaccination beliefs. It does not establish that urban or higher-socioeconomic-status girls were more aware, or that rural or tribal girls were less aware and more sceptical. The Methods identify parents, not girls, as the survey respondents; page numbers are unavailable in our copy. (LLM, conf=0.72)

    Experimental — accuracy not yet measured

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Authors
Degarege, A., Krupp, K., Fennie, K., Srinivas, V., Li, T., Stephens, D. P., & Madhivanan, P.
Affiliations
  • Florida International University (US)
  • Public Health Research Institute Of India (IN)
Corresponding author
Madhivanan, Purnima
ORCID
Venue
Vaccine
Publisher
Elsevier BV
Published
2019-02
Volume
37
Issue
7
Pages
945-955
ISSN
0264-410X (ISSN-L)
DOI
10.1016/j.vaccine.2019.01.012
PMC
PMC6351189
OpenAlex
W2910203053
Cited by
29
References
1
Citations by year
2026: 4 · 2025: 6 · 2024: 5 · 2023: 4 · 2022: 4 · 2021: 4 · 2020: 2
FWCI
1.90
Type
journal article
Language
en
Open access
Licence
www.elsevier.com/tdm/userlicense/1.0/ (tdm)
Locations
  • Vaccine (publishedVersion)
  • PubMed (publishedVersion)
  • Europe PMC (PubMed Central) (acceptedVersion)
  • PubMed Central (acceptedVersion)
Funders
  • Merck & Co., Inc
  • Florida International University
  • National Institute for Health
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
HPV vaccine, vaccine acceptance, adolescent girls, cervical cancer prevention, parental attitudes, geographic location, Mysore district
MeSH terms
Latent Class Analysis, Adolescent, Adult, Aged, Child, Cross-Sectional Studies, Female, Humans, India, Health Knowledge, Attitudes, Practice, Middle Aged, Parents, Patient Acceptance of Health Care, Surveys and Questionnaires, Papillomavirus Infections, Papillomavirus Vaccines, Young Adult

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