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Cited by 10Cervical Cancer and HPV ResearchVaccine Coverage and HesitancyWomen's cancer prevention and management

Acceptability of HPV vaccination for cervical cancer prevention amongst emerging adult women in rural Mysore, India: a mixed-methods study

Open access
Coursey, Kate, Muralidhar, Kiranmayee, Srinivas, Vijaya, Jaykrishna, Poornima, Begum, Fazila, Ningaiah, Nagalambika, Lee, Sung-Jae, Madhivanan, Purnima·2024·BMC Public Health
DOI 10.1186/s12889-024-19485-8PMC PMC11304586
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Abstract

Background: India has the highest number of estimated deaths from cervical cancer globally, with most cases attributed to Human papillomavirus (HPV). The World Health Organization recommends primary HPV vaccination for girls ages 9–14, with catch-up vaccination for young women ≥ 15 if feasible. India authorized a new, inexpensive HPV vaccine in 2022; given anticipated vaccine expansion, we conducted a mixed-methods study exploring acceptability of HPV catch-up vaccination for young emerging adult women in rural Mysore, India. Methods: Between September 2022-April 2023, participants were recruited with assistance from community health workers. In the qualitative phase, gender-stratified, audio-recorded focus group discussions (FGDs) were conducted in Kannada with emerging adults ages 18–26. FGDs were transcribed, translated, and analyzed using rapid approach to identify key HPV vaccination attributes. In the quantitative phase, a conjoint analysis was conducted to assess the impact of seven vaccination attributes on likelihood to vaccinate (LTV). Women ages 18–26 ranked LTV in eight hypothetical vaccination scenarios, and the relative impact of each attribute on LTV was calculated. All participants received education about cervical cancer, HPV, and HPV vaccination. Results: Fifty-two young adults (female = 31, male = 21) participated in seven FGDs, and 101 women participated in the conjoint analysis. Average age of the 153 participants was 22.5 years, 66.7% had married, and all had completed high school. Only 17.9% had heard of cervical cancer, and 2.7% knew of the HPV vaccine. FGDs identified seven HPV vaccination attributes: cost, vaccination location, family support, peer influence, dose number, side effects, and risk of acquiring HPV. In the conjoint analysis, all attributes except dose number significantly impacted LTV. Family support (impact score = 19.37, p < 0.0001) and peer influence (impact score = 18.01, p < 0.0001) had the greatest influence, followed by cost (impact score = 16.64, p < 0.0001) and HPV risk (impact score = 12.31, p < 0.0001). Vaccination location (government centers preferred) and side effects were also significant. Conclusion: Participants had poor knowledge of cervical cancer and HPV. Social attributes (family support, peer influence) had greatest impacts on LTV, and future studies should explore family-based interventions and peer education. Providing free vaccines at government centers through India’s national immunization program would maximize catch-up HPV vaccination for rural young women.

AI snapshot

Written from the paper’s full text.

TL;DR

In rural Mysore, India, emerging adult women and men had very low knowledge of cervical cancer, HPV, and HPV vaccination, but after education, social factors—family support and peer influence—most strongly shaped young women’s likelihood to vaccinate. The authors recommend free or subsidized catch-up HPV vaccination at government centers, family-based interventions, and peer education.

Key findings

Among 153 participants (52 FGD participants: 31 women, 21 men; 101 women in conjoint analysis), only 17.9% had heard of cervical cancer, 0.7% knew HPV causes cervical cancer, and 2.7% had heard of the HPV vaccine. In conjoint analysis, all attributes except dose number significantly impacted likelihood to vaccinate (LTV); family support had the greatest impact (19.37, p < 0.0001), followed by peer influence (18.01, p < 0.0001), cost (16.64, p < 0.0001), and HPV risk (12.31, p < 0.0001). Mean LTV across eight hypothetical scenarios ranged from 42.57 to 97.03 on a 100-point scale. Family support and peer influence had relatively greater impact among never-married women (26.89 and 22.73, respectively) and younger women aged 18–22 (21.22 and 20.96, respectively).

Methods

Mixed-methods study conducted September 2022–April 2023 in rural villages of Mysore District, Karnataka, India. Qualitative phase: seven gender-stratified, audio-recorded FGDs in Kannada with adults aged 18–26, analyzed using rapid qualitative analysis to identify HPV vaccination attributes. Quantitative phase: conjoint analysis with 101 women aged 18–26 who ranked LTV in eight hypothetical vaccination scenarios using a Plackett–Burman fractional factorial design; impact scores were calculated from individual regression coefficients and averaged, with one-sample t-tests for significance.

Limitations

The paper states small sample size, rural-only sampling, religious homogeneity, and high educational attainment may limit generalizability; education was provided immediately before conjoint analysis, so durability of knowledge and intentions is unknown; and the observational design precludes causal inference. Evident from the text: conjoint analysis included only women, so men’s preferences were not quantitatively measured, and LTV measured stated intention rather than actual vaccine uptake.

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

Integrity signals

Registry

Crossref · 10.1186/s12889-024-19485-8

Cites

60 of 60 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

34 of 49 cited sources checked · 20 supported · 0 flagged · accuracy not yet measured

  • Premisecitation

    Few studies have specifically examined vaccine acceptability in adult women ages 18-26, who are vaccine-eligible but too old to be reached through traditional, school-based HPV vaccine campaigns.

    “Few studies have specifically examined vaccine acceptability in adult women ages 18–26, who are vaccine-eligible but too old to be reached through traditional, school-based HPV vaccine campaigns [20].”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [20] Ahmed D, VanderEnde K, Harvey P, Bhatnagar P, Kaur N, Roy S, et al. Human papillomavirus (HPV) vaccine introduction in Sikkim state: Best practices from the first statewide multiple-age cohort HPV vaccine introduction in India-2018–2019. Vaccine. 2021;40(Suppl 1):A17–25. source

      The Background (page unavailable) says Sikkim’s school-based HPV campaign targeted girls aged 9–13, supporting the point that women aged 18–26 were outside that campaign’s target group. The paper does not establish that few studies examine vaccine acceptability in women aged 18–26, or address their vaccine eligibility. (LLM, conf=0.82)

      Experimental — accuracy not yet measured
  • Premisecitation

    Catch-up vaccination in the secondary target population (young women over 15) has been shown to decrease HPV infection rates.

    “Catch-up vaccination in this secondary target population has been shown to decrease HPV infection rates, [16, 17]”
    Quote in the paperNot a substantial claim2 of 2 sources checked
    • cites [16] Zhu FC, Hu SY, Hong Y, Hu YM, Zhang X, Zhang YJ, et al. Efficacy, immunogenicity and safety of the AS04-HPV-16/18 vaccine in Chinese women aged 18–25 years: End-of-study results from a phase II/III, randomised, controlled trial. Cancer Med. 2019;8(14):6195–211. source
    • cites [17] Yoshikawa H, Ebihara K, Tanaka Y, Noda K. Efficacy of quadrivalent human papillomavirus (types 6, 11, 16 and 18) vaccine (GARDASIL) in Japanese women aged 18–26 years. Cancer Sci. 2013;104(4):465–72. source
  • Premisecitation

    Knowledge is likely even poorer amongst less educated women and women from rural areas.

    “Knowledge is likely even poorer amongst less educated women and women from rural areas [22–25].”
    Quote in the paperNot a substantial claim2 of 4 sources checked
    • cites [22] Joshi SV, Chaudhari HR, Chaudhari NA. Effect of Education on Awareness, Knowledge, and Willingness to Be Vaccinated in Females of Western India. J Cancer Educ. 2020;35(1):61–8. source
    • cites [23] Kadian L, Gulshan G, Sharma S, Kumari I, Yadav C, Nanda S, et al. A Study on Knowledge and Awareness of Cervical Cancer Among Females of Rural and Urban Areas of Haryana. North India J Cancer Educ. 2021;36(4):844–9. source
    • cites [24] Shah P, Shetty V, Ganesh M, Shetty AK. Challenges to Human Papillomavirus Vaccine Acceptability among Women in South India: An Exploratory Study. Am J Trop Med Hyg. 2021;105(4):966–73. source

      The Results section reports participants’ view that HPV and vaccine awareness was particularly low in rural communities. The Discussion says the study oversampled healthcare workers, who likely knew more than the general public, but it does not assess knowledge by education level. The claim about less educated women is therefore not established by this paper. (LLM, conf=0.85)

      Experimental — accuracy not yet measured
    • cites [25] Sabeena S, Bhat PV, Kamath V, Aswathyraj S, Arunkumar G. Knowledge, Attitude and Practice Concerning Human Papilloma Virus Infection and its Health Effects among Rural Women, Karnataka, South India. Asian Pac J Cancer Prev. 2015;16(12):5053–8. source

      The Results and Abstract report that none of the women surveyed in a rural Karnataka village had heard of HPV, supporting the rural-women portion. The Discussion says HPV awareness was not correlated with education level in this study, so this paper does not support the claim that knowledge is poorer among less educated women. (LLM, conf=0.88)

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  • Premisecitation

    Cultural factors, including stigma surrounding STIs and fear of judgment from family and community members, may negatively impact vaccine acceptability.

    “Cultural factors, including stigma surrounding STIs and fear of judgment from family and community members, may negatively impact vaccine acceptability [7, 24].”
    Quote in the paperNot a substantial claim1 of 2 sources checked
    • cites [7] Chatterjee S, Chattopadhyay A, Samanta L, Panigrahi P. HPV and Cervical Cancer Epidemiology - Current Status of HPV Vaccination in India. Asian Pac J Cancer Prev. 2016;17(8):3663–73. source
    • cites [24] Shah P, Shetty V, Ganesh M, Shetty AK. Challenges to Human Papillomavirus Vaccine Acceptability among Women in South India: An Exploratory Study. Am J Trop Med Hyg. 2021;105(4):966–73. source
  • Premisecitation

    Conjoint analysis has not been used to assess HPV vaccine acceptability in India.

    “While conjoint analysis has been previously applied to vaccine and other biomedical research, [29–32] it has not been used to assess HPV vaccine acceptability in India.”
    Quote in the paperSubstantial claim4 of 4 sources checked
    • cites [29] Bridges JF, Hauber AB, Marshall D, Lloyd A, Prosser LA, Regier DA, et al. Conjoint analysis applications in health–a checklist: a report of the ISPOR Good Research Practices for Conjoint Analysis Task Force. Value Health. 2011;14(4):403–13. source

      The citation is attached to the preceding clause about prior applications. The “Conjoint analysis in health care studies” section lists biomedical applications, but does not mention vaccines. It also does not establish the citing authors’ separate statement about HPV vaccine acceptability in India (page unavailable). (LLM, conf=0.84)

      Experimental — accuracy not yet measured
    • cites [30] Asiedu GB, Breitkopf CR, Kremers WK, Ngo QV, Nguyen NV, Barenberg BJ, et al. Vietnamese Health Care Providers’ Preferences Regarding Recommendation of HPV Vaccines. Asian Pac J Cancer Prev. 2015;16(12):4895–900. source
    • cites [31] Ong AKS, Prasetyo YT, Lagura FC, Ramos RN, Salazar JML, Sigua KM, et al. Young adult preference analysis on the attributes of COVID-19 vaccine in the Philippines: A conjoint analysis approach. Public Health Pract (Oxf). 2022;4: 100300. source
    • cites [32] Simoni JM, Tapia K, Lee SJ, Graham SM, Beima-Sofie K, Mohamed ZH, et al. A Conjoint Analysis of the Acceptability of Targeted Long-Acting Injectable Antiretroviral Therapy Among Persons Living with HIV in the U.S. AIDS Behav. 2020;24(4):1226–36. source
  • Classified as probably not a substantial claim. 22
  • May combine two claims. 24

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

    Premisecitation

    Other barriers include cost, fear of side effects, perceived lack of need, and questions of vaccine efficacy.

    “Other barriers include cost, fear of side effects, perceived lack of need, and questions of vaccine efficacy [24, 26].”
    Quote in the paperNot a substantial claim1 of 2 sources checked
    • cites [24] Shah P, Shetty V, Ganesh M, Shetty AK. Challenges to Human Papillomavirus Vaccine Acceptability among Women in South India: An Exploratory Study. Am J Trop Med Hyg. 2021;105(4):966–73. source
    • cites [26] Montgomery MP, Dune T, Shetty PK, Shetty AK. Knowledge and acceptability of human papillomavirus vaccination and cervical cancer screening among women in Karnataka. India J Cancer Educ. 2015;30(1):130–7. source

  • May combine two claims.

    Premisecitation

    In a 2016 survey of Indian college students, only 46% of women knew that HPV was related to cervical cancer, while 44% knew the vaccine existed.

    “In a 2016 survey of Indian college students, only 46% of women knew that HPV was related to cervical cancer, while 44% knew the vaccine existed [21].”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [21] Rashid S, Labani S, Das BC. Knowledge, Awareness and Attitude on HPV, HPV Vaccine and Cervical Cancer among the College Students in India. PLoS ONE. 2016;11(11): e0166713. source

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

    Premisecitation

    Economic modeling suggests that inclusion of catch-up vaccination for older women can be a cost-effective way to decrease cervical cancer burden.

    “and economic modeling suggests that inclusion of catch-up vaccination for older women can be a cost-effective way to decrease cervical cancer burden [18, 19].”
    Quote in the paperNot a substantial claim2 of 2 sources checked
    • cites [18] Man I, Georges D, de Carvalho TM, Ray Saraswati L, Bhandari P, Kataria I, et al. Evidence-based impact projections of single-dose human papillomavirus vaccination in India: a modelling study. Lancet Oncol. 2022;23(11):1419–29. source

      The Discussion reports that catch-up vaccination in girls aged 11–20 years could be cost-effective, citing a separate unpublished economic analysis. The Results project reduced cervical cancer risk with catch-up vaccination extending to women aged 30, but the paper does not establish cost-effectiveness for those older cohorts. (LLM, conf=0.86)

      Experimental — accuracy not yet measured
    • cites [19] Chesson HW, Markowitz LE. The cost-effectiveness of human papillomavirus vaccine catch-up programs for women. J Infect Dis. 2015;211(2):172–4. source

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

    Premisecitation

    Among married women, spousal support or lack thereof additionally impacts vaccination and healthcare utilization.

    “Among married women, spousal support or lack thereof additionally impacts vaccination and healthcare utilization [27, 28].”
    Quote in the paperNot a substantial claim2 of 2 sources checked
    • cites [27] Giduthuri JG, Purohit V, Kudale A, Utzinger J, Schindler C, Weiss MG. Antenatal influenza vaccination in urban Pune, India: clinician and community stakeholders’ awareness, priorities, and practices. Hum Vaccin Immunother. 2021;17(4):1211–22. source

      The Results report that more than half of women with pregnancy experience would seek their husbands’ advice about antenatal vaccination; the Discussion likewise describes spouses’ role in vaccine decisions. The paper does not establish that spousal support or its absence affects healthcare utilization more generally. (LLM, conf=0.85)

      Experimental — accuracy not yet measured
    • cites [28] Thulaseedharan JV, Frie KG, Sankaranarayanan R. Challenges of health promotion and education strategies to prevent cervical cancer in India: A systematic review. J Educ Health Promot. 2019;8:216. source

  • May combine two claims.

    Findingcitation

    Most participants were middle class or below in socioeconomic strata, with per-capita monthly income less than 4,329 INR (53 USD).

    “Most participants were middle class or below in the socioeconomic strata, meaning their per-capita monthly income was less than 4,329 INR (53 USD);”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [47] Pentapati SSK, Debnath DJ. Updated BG Prasad’s classification for the year 2022. J Family Med Prim Care. 2023;12(1):189–90. source

      Table 2 of the cited paper gives the May 2022 per-capita monthly income range for class III as INR 2,544–4,239, with classes IV and V below that. It therefore supports an income cutoff below INR 4,240 for middle class or below, not the claimed INR 4,329. The paper does not report the citing study’s participant distribution. (LLM, conf=0.88)

      Experimental — accuracy not yet measured

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

    Premisecitation

    ASHAs and Anganwadi teachers are instrumental in providing frontline health services in rural India, and both played important roles in combating the COVID-19 pandemic, including coordinating vaccination efforts.

    “As trusted members of their local communities, ASHAs and Anganwadi teachers are instrumental in providing frontline health services in rural India, [66–68] and both played important roles in combating the COVID-19 pandemic, including coordinating vaccination efforts [68, 69].”
    Quote in the paperNot a substantial claim4 of 4 sources checked
    • cites [66] Birje S, Patil AD, Munne KR, Chavan V, Joshi BN, Akula A, et al. Enablers & challenges of tribal women & health system for implementation of screening of non-communicable diseases & common cancers: A mixed-methods study in Palghar district of Maharashtra. India Indian J Med Res. 2022;156(2):319–29. source

      The Results and Discussion describe ASHAs as trusted frontline links between tribal women and the health system. They do not establish a comparable role for Anganwadi teachers or describe either group coordinating COVID-19 vaccination. A Results quotation mentions taking blood-pressure readings at a vaccination programme, but does not identify it as a COVID-19 programme. (LLM, conf=0.88)

      Experimental — accuracy not yet measured
    • cites [67] Abdel-All M, Abimbola S, Praveen D, Joshi R. What do Accredited Social Health Activists need to provide comprehensive care that incorporates non-communicable diseases? Findings from a qualitative study in Andhra Pradesh, India. Hum Resour Health. 2019;17(1):73. source

      The Introduction (page not supplied) describes ASHAs as community health workers who connect people to public health services, including immunisation, and the Results describe their trusted role in their communities. The cited paper does not establish the corresponding role of Anganwadi teachers or address either group's work during COVID-19, including vaccination coordination. (LLM, conf=0.89)

      Experimental — accuracy not yet measured
    • cites [68] Harikrishna BN, Jothula KY, Nagaraj K, Prasad VG. Utilisation of Anganwadi services among pregnant women in rural Telangana: A cross sectional study. J Family Med Prim Care. 2020;9(7):3343–8. source

      The Introduction describes anganwadi workers providing health education, immunization, check-ups and referrals, supporting their role in frontline health services. The Results report vaccine use at anganwadi centres among pregnant women in rural Telangana. The paper does not establish ASHAs’ role or discuss either group’s COVID-19 response or coordination of COVID-19 vaccination; searches for ASHAs and COVID-19 found no such passage. Page numbers were unavailable in our copy. (LLM, conf=0.88)

      Experimental — accuracy not yet measured
    • cites [69] Gore M, Kawade A, Smith P, Pinnock H, Juvekar S, Collaboration R. Working as frontline health facilitators, service providers, program supporters, and social health activists in Indian hilly terrain areas: A qualitative study of accredited social health activists’ experiences before and during the COVID-19 pandemic. J Glob Health. 2022;12:05052. source

      The Results (Service provider: First point of health care) describe ASHAs as frontline providers in villages, and the Results (Healthcare facilitator) document their COVID-19 work and say Anganwadi sevika and schoolteachers initially assisted. The paper does not establish that Anganwadi teachers provided frontline health services or that either group coordinated COVID-19 vaccination efforts; its discussion of child immunization concerns routine services. (LLM, conf=0.87)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Study design and conductcitation

    Sample size for conjoint analysis was selected based on literature review and is consistent with other similar conjoint analysis pilots that have generated statistically meaningful results.

    “Sample size for conjoint analysis was selected based on literature review and is consistent with other similar conjoint analysis pilots that have generated statistically meaningful results [43–46].”
    Quote in the paperSubstantial claim4 of 4 sources checked
    • cites [43] Galea JT, Kinsler JJ, Salazar X, Lee SJ, Giron M, Sayles JN, et al. Acceptability of pre-exposure prophylaxis as an HIV prevention strategy: barriers and facilitators to pre-exposure prophylaxis uptake among at-risk Peruvian populations. Int J STD AIDS. 2011;22(5):256–62. source
    • cites [44] Lee SJ, Brooks RA, Newman PA, Seiden D, Sangthong R, Duan N. HIV vaccine acceptability among immigrant Thai residents in Los Angeles: a mixed-method approach. AIDS Care. 2008;20(10):1161–8. source
    • cites [45] Lee SJ, Brooks R, Bolan RK, Flynn R. Assessing willingness to test for HIV among men who have sex with men using conjoint analysis, evidence for uptake of the FDA-approved at-home HIV test. AIDS Care. 2013;25(12):1592–8. source
    • cites [46] Newman PA, Duan N, Lee SJ, Rudy ET, Seiden DS, Kakinami L, et al. HIV vaccine acceptability among communities at risk: the impact of vaccine characteristics. Vaccine. 2006;24(12):2094–101. source

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

    Premisecitation

    The expanded use of mobile Internet technology to access health information in rural India offers a potential avenue to deliver education to community members.

    “The expanded use of mobile Internet technology to access health information in rural India offers a potential avenue to deliver education to community members [57].”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [57] Yadav K, Hariprasad R, Gupta R, Upadhayay S, Sharma V, Kumari M, et al. Cancer awareness & its association with demographic variables & mobile phone usage among the rural population of a district in north India. Indian J Med Res. 2022;156(1):94–103. source

  • May combine two claims.

    Premisecitation

    A recent study in rural India piloted a family-centered sexual health education intervention to improve uptake of HPV testing for women, providing story-based audio-visual education to both women and a male family member; the intervention demonstrated improved attitudes and knowledge regarding cervical cancer screening and reduced STI-related stigma.

    “A recent study in rural India piloted a family-centered sexual health education intervention to improve uptake of HPV testing for women, providing story-based audio-visual education to both women and a male family member; the intervention demonstrated improved attitudes and knowledge regarding cervical cancer screening and reduced STI-related stigma [53].”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [53] Vahabi M, Mishra G, Pimple S, Wong JP, Khan M, Prakash V, et al. Effectiveness of family-centred sexual health education and HPV self-sampling in promoting cervical cancer screening among hard-to-reach indian women in rural and tribal areas: a community-based pilot study. BMC Public Health. 2023;23(1):671. source

  • May combine two claims.

    Findingown data

    Qualitative data suggest that community members may not understand the need to vaccinate low-risk, unmarried women, consistent with other literature from India.

    “Our qualitative data suggest that community members may not understand the need to vaccinate low-risk, unmarried women, which is consistent with other literature from India [59, 60].”
    Quote in the paperSubstantial claim1 of 2 sources checked
    • cites [59] Padmanabha N, Kini JR, Alwani AA, Sardesai A. Acceptability of human papillomavirus vaccination among medical students in Mangalore. India Vaccine. 2019;37(9):1174–81. source
    • cites [60] Kataria I, Siddiqui M, Treiman K, Foley S, Anand M, Biswas S, et al. Awareness, perceptions, and choices of physicians pertaining to human papillomavirus (HPV) vaccination in India: A formative research study. Vaccine X. 2022;12: 100228. source

      The Results (Physician challenges with HPV vaccination; page unavailable) report physicians’ accounts that some parents saw no need to vaccinate daughters they believed would not be sexually active at ages 9–14. This supports a similar concern in India, but the paper does not specifically report community members’ views about vaccinating low-risk, unmarried women. (LLM, conf=0.84)

      Experimental — accuracy not yet measured

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationcitation

    Including local stakeholders in devising HPV vaccination interventions will be critical for program success in Indian communities.

    “Including local stakeholders in devising HPV vaccination interventions will be critical for program success in Indian communities [71].”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [71] Mandal R, Banerjee D, Gupta K, Chatterjee P, Vernekar M, Ray C. Experience of Human Papillomavirus Vaccination Project in a Community Set Up-An Indian Study. Asian Pac J Cancer Prev. 2021;22(3):699–704. source

      The Materials and Methods section (page unavailable) says the team consulted local stakeholders before developing its questionnaire and that local organizers played a key role in encouraging the community. The Discussion (page unavailable) says established local networks made recruitment easier. These observations support involving stakeholders, but the paper does not establish that including them in devising vaccination interventions is critical for program success across Indian communities. (LLM, conf=0.85)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Findingown data

    Pre-existing knowledge of cervical cancer, HPV as a cause of cervical cancer, and HPV vaccination among female participants was 17.6%, 0.8%, and 1.5%, respectively.

    “pre-existing knowledge of cervical cancer, HPV as a cause of cervical cancer, and HPV vaccination amongst female participants were 17.6%, 0.8%, and 1.5%, respectively.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Among logistical attributes, cost had the greatest impact on LTV, followed by vaccination location.

    “Of the logistical attributes presented in conjoint analysis, cost had the greatest impact upon LTV, followed by vaccination location, with participants favoring vaccination at government centers as part of the National Immunization Program.”
    • Also stated in: § Conclusion · plain
      “Cost was the most impactful non-social attribute”
    Quote in the paperSubstantial claim

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

    Findingown data

    All agreed that including the HPV vaccine in the National Immunization Program for young women would legitimize the vaccine and encourage uptake.

    “all agreed that including the HPV vaccine in the National Immunization Program for young women would legitimize the vaccine and encourage uptake.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    HPV risk had a greater impact among older women and ever-married women compared to younger and never-married women.

    “HPV risk had a greater impact among older women (impact score = 16.04, p < 0.0001), moving into second place behind family support, and among ever-married women (impact score = 14.61, p < 0.0001) compared to younger and never-married women.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Participants felt that seeing other young women from their community take the HPV vaccine and receiving information about the vaccine from peers would be an important facilitator for vaccination.

    “Participants felt that seeing other young women from their community take the HPV vaccine and receiving information about the vaccine from peers would be an important facilitator for vaccination.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Vaccination location (government centers preferred) and side effects were also significant.

    “Vaccination location (government centers preferred) and side effects were also significant.”
    Quote in the paperNot a substantial claim
    • The authors state this as an assumption: There are no interactions between the seven HPV vaccination attributes.

  • May combine two claims.

    Findingown data

    Side effects were more impactful among never-married women, moving ahead of HPV risk.

    “Side effects were more impactful among never-married women (impact score = 16.7, p < 0.0001), moving ahead of HPV risk.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Most women who participated in FGDs did not perceive themselves personally to be at risk for HPV; this was particularly true for unmarried women.

    “Most women who participated in FGDs did not perceive themselves personally to be at risk; this was particularly true for unmarried women”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingcitation

    Minor side effects was a significant negative predictor of LTV for unmarried women, and FGD participants expressed concern about more serious gynecologic and fertility-related side effects despite receiving education about the well-established safety record of HPV vaccines.

    “Minor side effects was a significant negative predictor of LTV for unmarried women in particular, and FGD participants expressed concern about more serious gynecologic and fertility-related side effects, despite receiving education about the well-established safety record of HPV vaccines [61].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [61] World Health Organization. Safety of HPV vaccines. World Health Organization; 2017. Accessed 25 Apr 2023. Available from: https://www.who.int/groups/global-advisory-committee-on-vaccine-safety/topics/human-papillomavirus-vaccines/safety.

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

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

    Premisecitation

    WHO recommends primary HPV vaccination for girls ages 9-14, with catch-up vaccination for young women ≥15 if feasible.

    “WHO guidelines recommend vaccination for girls ages 9–14 as a primary target population. Young women over age 15 are a secondary target population for catch-up vaccination if affordable and feasible, [11]”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [11] World Health Organization. Human papillomavirus vaccines: WHO position paper (2022 update). Wkly Epidemiol Rec. 2022;50(97):645–72.

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • May combine two claims.

    Premisecitation

    The Serum Institute of India launched a new, indigenously-developed HPV vaccine in September 2022 at significantly cheaper cost per-dose than existing vaccines.

    “First, the Serum Institute of India, a prominent vaccine manufacturer in India, launched a new, indigenously-developed HPV vaccine in September 2022 at significantly cheaper cost per-dose than existing vaccines; the government subsequently announced a gradual roll-out for adolescent girls as part of India’s National Immunization Program [10].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [10] Burki TK. India rolls out HPV vaccination. Lancet Oncol. 2023;24(4): e147. source

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

    Study design and conductnone given

    The study was approved by PHRII's Institutional Ethics Review Board and by the University of California Los Angeles Institutional Review Board.

    “This study was approved by PHRII’s Institutional Ethics Review Board and by the University of California Los Angeles Institutional Review Board.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationown data

    Providing free vaccines at government centers through India's national immunization program would maximize catch-up HPV vaccination for rural young women.

    “Providing free vaccines at government centers through India’s national immunization program would maximize catch-up HPV vaccination for rural young women.”
    Quote in the paperNot a substantial claim
    • The authors state this as an assumption: There are no interactions between the seven HPV vaccination attributes.

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

    Study design and conductnone given

    Two authors independently summarized each FGD using bullet point format, and summaries were discussed amongst the authors to reach consensus.

    “These domains were incorporated into a summary template, and two authors (KC and KM) independently summarized each FGD using bullet point format. Summaries were discussed amongst the authors to reach consensus”
    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 conductreasoning

    This is an observational study and no causal inference can be drawn from it.

    “Thirdly, this is an observational study and no causal inference can be drawn from this study.”
    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

    Because most participants had no knowledge of cervical cancer or HPV, education was provided immediately prior to administering the conjoint analysis survey.

    “Secondly, because most participants had no knowledge of cervical cancer or HPV, education was provided to participants immediately prior to administering the conjoint analysis survey.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductcitation

    Guide questions were developed using the Increasing Vaccination Model (IVM) as a theoretical framework.

    “Guide questions were developed using the Increasing Vaccination Model (IVM) as a theoretical framework, which postulates that what people think and feel, social processes, and direct behavioral changes are the three primary factors driving vaccination [35, 36].”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [35] Brewer NT, Chapman GB, Rothman AJ, Leask J, Kempe A. Increasing Vaccination: Putting Psychological Science Into Action. Psychol Sci Public Interest. 2017;18(3):149–207. source
    • cites [36] Brewer NT. What Works to Increase Vaccination Uptake. Acad Pediatr. 2021;21(4S):S9–16. source

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

    Study design and conductnone given

    Only women who were able to give informed consent were recruited to participate in the study.

    “Only women who were able to give informed consent were recruited to participate in the study.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationreasoning

    Providing formal catch-up vaccination recommendations as part of the National Immunization Program, with the vaccine available free or partially-subsidized at government centers, would increase acceptability of HPV catch-up vaccination.

    “Providing formal catch-up vaccination recommendations as part of the National Immunization Program, with the vaccine available free or partially-subsidized at government centers, would increase acceptability of HPV catch-up vaccination.”
    Quote in the paperNot a substantial claim

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

    Study design and conductnone given

    The regression model was not adjusted for additional variables.

    “The regression model was not adjusted for additional variables.”
    Quote in the paperNot a substantial claim

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

    Study design and conductnone given

    Scenario cards were pilot tested in the community to ensure they were culturally relevant and identifiable.

    “Scenario cards were pilot tested in the community to ensure they were culturally relevant and identifiable.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductnone given

    By using a mixed-methods approach, the study was able to gauge community-level perceptions about the HPV vaccine while objectively measuring individual-level factors that affect a woman's decision to take it.

    “We believe that by using a mixed-methods approach, we were able to gauge community-level perceptions about the HPV vaccine while objectively measuring individual-level factors that affect a woman’s decision to take it.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

    Study design and conductreasoning

    The study produced robust findings that can be translated into policy or incorporated into existing strategies with the upcoming roll-out of India's first indigenous HPV vaccine.

    “We were able to produce robust findings that can be translated into policy or incorporated into existing strategies with the upcoming roll-out of India’s first indigenous HPV vaccine.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

    Interpretationreasoning

    Mobilizing local stakeholders, offering vaccination at government centers, and incorporating official recommendations for catch-up HPV vaccination into the National Immunization Program would maximize uptake amongst rural young women.

    “Mobilizing local stakeholders, offering vaccination at government centers, and incorporating official recommendations for catch-up HPV vaccination into the National Immunization Program would maximize uptake amongst rural young women.”
    Quote in the paperNot a substantial claim

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

    Premisecitation

    In another study of online administration of HPV educational materials to Indian parents, short videos were found to be the most effective means of increasing awareness.

    “in another study of online administration of HPV educational materials to Indian parents, short videos were found to be the most effective means of increasing awareness [56].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [56] Abra Pearl CT, Navaneetha M, Malarvilizhi S, Mony K. Online educational program for parents of adolescents on human papillomavirus vaccination during COVID pandemic: A feasibility check. Indian J Public Health. 2022;66(2):104–8. source
36 of 36

  • The paper relies on this without support.

    Young men's opinions as husbands, brothers, and fathers may impact women's vaccine uptake.

    “Young men were included in the qualitative phase because their opinions as husbands, brothers, and fathers may impact women’s vaccine uptake.”

  • The authors state this as an assumption.

    There are no interactions between the seven HPV vaccination attributes.

    “This design allowed us to estimate the main effects of each attribute, assuming that there were no interactions between the attributes [42].”

  • The paper relies on this without support.

    HPV catch-up vaccination is often given up to age 26.

    “an upper age limit of 26 was chosen because HPV catch-up vaccination is often given up to this age.”

  • The paper relies on this without support.

    Responses to hypothetical vaccination scenarios reflect real-world vaccination decisions.

    “Likelihood to vaccinate (LTV) against HPV for eight hypothetical vaccination scenarios in Mysore, India (n = 101)”

  • The paper relies on this without support.

    Education provided immediately before the conjoint analysis survey was sufficient for participants to understand the HPV vaccination attributes.

    “education was provided to participants immediately prior to administering the conjoint analysis survey.”

  • The paper relies on this without support.

    The Serum Institute of India's HPV vaccine costs 1,000 INR per dose.

    “At its current estimated cost of 1,000 INR per dose”

  • The paper relies on this without support.

    The study is the first in India to employ conjoint analysis for HPV vaccination decision-making.

    “It is the first study in India to employ conjoint analysis to better understand contributors to HPV vaccination decision-making.”
7 of 7

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.

  • Recruitment statement excludes men who participated

    Minor

    The ethics statement says only women were recruited, but the results report 21 men in the focus group discussions.

1 of 1

Cites

Flagged first, then by citations

Research works printed but not linked: 1

  1. World Health Organization. Human papillomavirus vaccines: WHO position paper (2022 update). Wkly Epidemiol Rec. 2022;50(97):645–72.

Cited by

Sorted by citations

Related

Authors
Coursey, K., Muralidhar, K., Srinivas, V., Jaykrishna, P., Begum, F., Ningaiah, N., Lee, S.-J., & Madhivanan, P.
Affiliations
  • University of California, Los Angeles (US)
  • JSS Academy of Higher Education and Research (IN)
  • Public Health Research Institute Of India (IN)
  • University of Arizona (US)
Corresponding author
Coursey, Kate
ORCID
Venue
BMC Public Health
Publisher
Springer Science and Business Media LLC
Published
2024-08-07
Volume
24
Issue
1
Pages
2139-2139
ISSN
1471-2458 (ISSN-L)
DOI
10.1186/s12889-024-19485-8
PMC
PMC11304586
OpenAlex
W4401397496
Semantic Scholar
12984fe07209e927e358839afd80dcdd90bb2caa
Cited by
10
References
60
Citations by year
2026: 5 · 2025: 5
FWCI
2.60
Type
journal article
Language
en
Open access
Licence
Locations
  • BMC Public Health (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • eScholarship (California Digital Library) (submittedVersion, cc-by)
  • PubMed Central (submittedVersion, cc-by)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion)
Funders
  • National Institute of Mental Health (P30MH058107)
  • Fogarty International Center (D43TW010540, D43TW010332)
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 vaccination, cervical cancer prevention, vaccine acceptance, catch-up vaccination, emerging adult women, rural women, vaccine attributes, family support, peer influence, vaccine cost, vaccine side effects, conjoint analysis, health education, cervical cancer awareness, community health workers
MeSH terms
Adolescent, Adult, Uterine Cervical Neoplasms, Female, Humans, India, Health Knowledge, Attitudes, Practice, Patient Acceptance of Health Care, Rural Population, Focus Groups, Papillomavirus Infections, Qualitative Research, Papillomavirus Vaccines, Young Adult

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-16.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-16.

Cited sources are checked by gpt-6-sol.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

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