|Year : 2018 | Volume
| Issue : 3 | Page : 233-237
Cervical cancer awareness and HPV vaccine acceptability among females in Delhi: A cross-sectional study
Jyoti Singh, Brototi Roy, Anshu Yadav, Shumaila Siddiqui, Aarzoo Setia, Ramya Ramesh, Kritika Singh
Department of Zoology, Maitreyi College, Chanakyapuri, University of Delhi, New Delhi, India
|Date of Web Publication||28-Jan-2019|
Dr. Brototi Roy
Department of Zoology, Maitreyi College, Chanakyapuri, University of Delhi, New Delhi
Source of Support: None, Conflict of Interest: None
AIMS: The aim of this study is to assess the awareness about cervical cancer and the acceptability of cytological screening and vaccine against human papilloma virus (HPV) among women in Delhi, the national capital of India. MATERIALS AND METHODS: A cross-sectional survey of women was conducted in Delhi to assess the awareness of cervical cancer and acceptability of Papanicolaou (Pap) test and HPV vaccine. The sample size of the population was 450, and a pre-tested questionnaire was administered to them. RESULTS: Majority of the participants (85.11%) were aware of cervical cancer and were willing to undergo diagnosis by Pap test (84.6%). As far as vaccination was concerned, 63.14% found the HPV vaccine acceptable for their daughters. However, very few participants were willing to vaccinate themselves against HPV. CONCLUSION: The high awareness among females in Delhi about cervical cancer and acceptability of screening programs, if done free of cost, shows a positive trend. The only inhibition about HPV vaccine was primarily due to concerns about postvaccination complications. However, inclusion of HPV vaccine in Government-sponsored immunization program would go a long way in increasing the acceptability of the vaccine.
Keywords: Awareness, cervical cancer, Delhi, HPV vaccine, Pap test
|How to cite this article:|
Singh J, Roy B, Yadav A, Siddiqui S, Setia A, Ramesh R, Singh K. Cervical cancer awareness and HPV vaccine acceptability among females in Delhi: A cross-sectional study. Indian J Cancer 2018;55:233-7
|How to cite this URL:|
Singh J, Roy B, Yadav A, Siddiqui S, Setia A, Ramesh R, Singh K. Cervical cancer awareness and HPV vaccine acceptability among females in Delhi: A cross-sectional study. Indian J Cancer [serial online] 2018 [cited 2019 Apr 26];55:233-7. Available from: http://www.indianjcancer.com/text.asp?2018/55/3/233/250887
| » Introduction|| |
Cervical cancer or the carcinoma of cervix is the second most common type of cancer found in women worldwide. In developing countries, including India, it is the most common cancer causing death in women. In India, every year 1,22,800 women are diagnosed with cervical cancer and almost half of them die from the disease., Indian women face a 2.5% cumulative lifetime risk and 1.4% cumulative death risk from cervical cancer. Alarmingly, about 6.6% of women in the general population are estimated to harbor cervical HPV infection. Late detection due to nonexistent or inadequate screening options and unavailable or unaffordable standard treatment has accentuated the problem in developing countries. The HPV serotypes 16 and 18 account for nearly 76.7% of cervical cancer in India. The disease is a huge burden on society as it consumes resources at a staggering rate in the way of medical, nonmedical spending, and lost productivity. According to recent ICMR findings, deaths due to cervical cancer in India have increased rapidly during the last 2 years.
Human papilloma virus (HPV) is the causative agent of cervical cancer. They are small deoxy-ribonucleic acid (DNA) viruses and are classified according to the DNA sequence. More than 100 HPV serotypes have been reported, of which 18 are categorized as the high-risk type. Molecular studies have shown that types 16 and 18 are the most oncogenic and type 16 is the most prevalent. The infection with HPV can result in intraepithelial neoplasia and invasive cervical cancer., HPVs can infect basal epithelial cells of the skin or inner lining of tissues and are categorized as cutaneous types or mucosal types. Although HPV infection is considered essential for the transformation of the cervical epithelial cells, it is not sufficient, and a variety of cofactors and molecular events influence further development and progression of disease.
There are various screening tests available for detection of cervical cancer. In 2013 and 2014, WHO published guidelines on the screening of precursor lesions for women. This includes cytological screening by Papanicolaou or Pap test, simple visual inspection with acetic acid (VIA), and DNA testing for HPV. Among these, Pap test has the lowest sensitivity (57%) whereas the highest sensitivity is that of visual inspection with acetic acid (VIA, 72%). Moreover, cytological screenings require an established laboratory, highly trained cytotechnologists, and up to three visits for screening and evaluation of cytologic abnormalities. Therefore, it is difficult to implement and sustain in settings with limited resources. The HPV test by hybrid capture II assay along with the current screening modalities shows great promise in early detection and hence prevention of cervical cancer. However, large scale routine screening is difficult in developing countries like India. Thus, in the present scenario an effective vaccine against the high-risk strains of HPV shows great promise. In India, two globally licensed vaccine, a quadrivalent vaccine (Gardasil™ marketed by Merck) and a bivalent vaccine (Cervarix™ marketed by GlaxoSmithKline) are available.
Regardless of the threat posed due to cervical cancer, ignorance, and less acceptability of screening as well as of vaccination is a big challenge in the prevention of the disease. In view of this, the present study was undertaken in Delhi to assess the awareness about cervical cancer and, acceptance of Pap test and HPV vaccine among women. Delhi, the national capital of India is an urban agglomeration with a population of 11,034,555 and an average literacy of 87.39%.
| » Materials and Methods|| |
Sample size: We carried out the questionnaire-based survey in Delhi, the capital of India. We chose a confidence level of 95%, 0.5 standard deviation, and a margin of error of +/–5%, and estimated the sample size as 385. The final sampling size was increased to 450 considering that females who answered the first question in negative would be excluded from further study.
The questionnaire was designed in English by a panel of researchers and medical practitioners based on an extensive review of published literature. A pilot study was conducted with 10 random participants to assess the feasibility and acceptability of questions. Thereafter, it was improved on the lines of suggestions given by the participants. The questionnaire was translated into Hindi and then verified by back translation.
The questionnaire has two main parts: (i) awareness of cervical cancer, its mode of transmission, and willingness to undergo diagnosis by Pap test, and (ii) awareness about means of prevention, HPV vaccine, and acceptability of HPV vaccine.
Five female researchers were extensively trained for 1 week to conduct the structured face-to-face interviews. Researchers approached the participants at public places, colleges, and offices. Only females in the age group 16–65 years were included in the study. Participants were given a verbal explanation of the objectives and general structure of the study.
The awareness about cervical cancer was investigated among all the participants. Those who had heard about cervical cancer were further asked about its mode of transmission, and their willingness to undergo diagnosis if it was government sponsored. We also enquired among these participants whether they thought that cervical cancer was preventable and did they know about the HPV vaccine. We provided the participants information about the vaccine and then tried to assess the acceptability of vaccine against HPV. The participants were also asked that whether the inclusion of HPV vaccine in government sponsored National Immunization program would increase its acceptability.
All the participants were assured of confidentiality. Only willing participants were included in the study and they gave written informed consent. They were further apprised that participation was anonymous and they had full right of withdrawal after reading the questionnaire.
| » Results|| |
Demographic characteristic of the sample
Of the 450 females surveyed, majority were in the 16–25 age group [Table 1]. The mean age of the sample population was 33.19 ± 11.95 years. Most of the participants were educated and 74.44% were either graduates or had higher education [Table 1].
|Table 1: Association of socio-demographic characters to awareness about cervical cancer, and acceptability of Pap test and HPV vaccine|
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Knowledge about cervical cancer and its mode of transmission
An overwhelming majority (85%) of the females surveyed had heard about cervical cancer. Among the 383 women who were aware or had heard about cervical cancer, only 32.4% (n = 124) believed that it was sexually transmitted [Table 2].
|Table 2: Perceptions about the mode of transmission of cervical cancer. The women who were aware of cervical cancer (n=383) were asked about the mode of transmission of cervical cancer|
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Willingness to undergo diagnosis through Pap smear More Details
When the participants were informed about free screening programs organized for cervical cancer at certain government hospitals, majority of them (84.6%) were willing to undergo screening for cervical cancer. Factors such as social stigma (27.1%), procedure being invasive (22.1%), and the belief that they cannot be affected by HPV (18.6%) acted as barrier for HPV screening among the 59 participants who were unwilling to undergo free diagnosis [Table 3].
Knowledge about prevention and HPV vaccine
63.2% (n = 242) participants believed that cervical cancer can be prevented. Majority of the participants who were aware of prevention responded that the means of prevention could be like other sexually transmitted diseases or by vaccination. 22.3% (n = 52) females reported that both these means could help in prevention of cervical cancer [Table 4]. All participants aware about cervical cancer (n = 383) were enquired about HPV vaccine. 59.8% (n = 229) of the participants had never heard about the HPV vaccine or vaccine against cervical cancer.
Acceptability of HPV vaccine
To assess HPV vaccine acceptability among the females of Delhi, we provided females with brief information related to the vaccine and tried to find out whether they have been vaccinated, or planned to vaccinate their daughters. The participants without children were included in this hypothetical question. However, some participants (n = 71) refused to answer the hypothetical question and were excluded from this question. 61.82% (n = 196) of the participants had either vaccinated their daughter(s) already or were willing to vaccinate their daughters against HPV. The participants who were against vaccination (38.17%; n = 121) cited various reasons, the primary being their concern about postvaccination complications as it is a new vaccine [Table 5].
|Table 5: Reasons cited by participants (n=121) for not planning to vaccinate their daughters against HPV|
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Next we asked all the participants (n = 383) whether they have been vaccinated or are willing to vaccinate themselves against HPV. Most of the females (91.4%; n = 350) reported being unvaccinated and unwilling to vaccinate themselves. The primary reason as stated by the participants being their anxiousness regarding the postvaccination complication and their limited knowledge about the vaccine [Table 6].
|Table 6: Reasons cited by participants (n=350) for not being interested to vaccinate themselves against cervical cancer|
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To understand the role of government in increasing acceptance of the HPV vaccine, we asked the participants that whether acceptability of the vaccine would increase if it is sponsored by the government and is included in the National Immunization program. Majority of the females surveyed (87.7%; n = 336) reported in affirmative to this question.
| » Discussion|| |
Most of the women surveyed in Delhi had heard about cervical cancer. The reason for this might be that our sample population was constituted mainly of women who were either graduate or had higher education. However, among the women who were aware of cervical cancer the knowledge about its mode of transmission was poor. One third of the population knew that HPV is sexually transmitted. However, the rest of the females surveyed attributed various factors for transmission of HPV, genetic mode of transmission being one of them. In a similar survey in Karnataka, India, almost half of the sample population was aware that cervical cancer is a sexually transmitted disease.
The next part of the study aimed to assess the participants' willingness to undergo diagnosis of cervical cancer by Pap smear. Screening of precancerous lesions and treating them is an important parameter for effective cancer prevention. Screening for cervical cancer can be done through cytological tests, visual inspection or HPV test. Although cytological test commonly known as Pap test has many limitations, it is still a very common test used for detecting precancerous lesions. The participants were informed about the details of the test and its free availability at certain government hospitals. Majority of the participants were willing to undergo screening. However, the number in the present study may be inflated as it was a hypothetical question for most of the participants. The actual number who would eventually undergo screening might be much less. In a previous study among female medical personnel in Delhi, it was found that only 19.7% of the participants underwent Pap test. Most of them cited that it was not the ideal time for them to be tested. Also, inaccessibility, social stigma, and side-effects were cited as deterrents. In a similar survey-based study at Karnataka and central India, 21% and 3% of the respondents, respectively, were willing to get a Pap smear., In the present study, it was seen that social stigma is a deterrent for many. Also, as Pap smear is an invasive test, many women felt uncomfortable about undergoing the test. Visual inspection (VI) methods that are economical, effective, and viable are suggested as an alternative to Pap test. Several studies have suggested that nurses and health-care workers without specific expertise for cervical cancer screening could be trained for visual inspection. Moreover, a study showed that screening and treatment strategy involving VI considerably decreased the incidence of cervical cancer and drastically reduced the cost of cancer management.
Although, majority of the sample population believed that cervical cancer was a preventable disease, most of them were unaware of the HPV vaccine. However, when educated about vaccine against cervical cancer, most of them were interested to vaccinate their daughters. The results are comparable to the high acceptance of HPV vaccine reported among parents in Mysore, India  and also to the actual vaccine coverage rates reported in a vaccine delivery pilot project in Andhra Pradesh and Gujarat. The high acceptance rates of vaccination among survey population in Delhi may be due to the detailed information the participants received about cervical cancer and the vaccines. In Kolkata, Basu and Mittal had reported an increase in the acceptance level of vaccine after parents were provided with detailed factsheets about cervical cancer and HPV vaccines. As far as vaccination for themselves were considered, the majority of them had inhibitions. The unwillingness to vaccinate themselves or their daughters was primarily due to anxiousness about postvaccination complications as they felt that the vaccine was comparatively new in the market.
Interestingly, participants felt that the acceptance level of HPV vaccines would increase considerably if the HPV vaccine was part of the National Immunization program. A major milestone in cervical cancer prevention in Delhi has been the introduction of HPV vaccine as a public health program for school children. This corroborates well with the fact that Government sponsored immunization program has been a big success in India. In addition, the health-care providers play an influential role. It has been reported both in Mysore  and Kolkata  that parents are more willing to vaccinate their daughters when advised by medical practitioners. Unfortunately, as has been suggested by Montgomary et al., the medical fraternity has failed to spread much awareness about cervical cancer and HPV vaccine in India till date.
| » Conclusions|| |
The present study reflects that although females in Delhi were aware of cervical cancer, there was very little knowledge about its preventive methods including screening by Pap smear and HPV vaccines. There is an urgent need to sensitize women about early detection of precancerous lesions and subsequently its prevention. Also, the stigma related to Pap smear needs to be dispelled. In addition to screening camps, strong and supportive advocacy program is the need of the hour. The social and news media as well as celebrity endorsement can play a significant role in mobilizing mass mindset. Current literature also emphasizes the importance of self-screening to increase the participation of unscreened women and ultimately promote a decrease in incidence and mortality from cervical cancer. As far as HPV vaccination is concerned, educating health-care professionals on how to communicate with parents to encourage HPV vaccination would greatly enhance the uptake. The government also needs to step in and include the HPV vaccine in the National Immunization program to control the menace of this completely preventable disease.
The present study however had many limitations. The participants were selected from specific places such as colleges, offices, and adjoining areas; and hence the females were mostly educated and sample was biased. Thus, it is difficult to comment on the generalizability of the findings to the wider population of Delhi. In addition, the study focused on acceptability of the HPV vaccine rather than its uptake. The question regarding vaccinating their daughters was hypothetical for many participants and also whether the intention to vaccinate their daughters or themselves would actually translate into behavior was obscure. Moreover, the use of close-ended questionnaire may have excluded many potential reasons for nonacceptance of Pap smear test and HPV vaccines.
We are grateful to Dr. Moushumi Bhardwaj, ICPO, Noida and Dr. Satish Gupta, Delhi for their valuable suggestions. The questionnaire was translated into Hindi with the help of Dr. Satish Gupta and Dr. Renu Gupta. We acknowledge the support and encouragement of Principal, Maitreyi College.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| » References|| |
GLOBOCAN 2012 (IARC) Section of Cancer Surveillance (17/12/2015). 2015.
Karthigeyan. Cervical cancer in India and HPV vaccination. Indian J Med Paediatr Oncol 2012;33(1):7-12.
Sreedevi A, Javed R, Dinesh A. Epidemiology of cervical cancer with special focus on India. Int J Women's Healt. 2015;7:405-14.
Cervical cancer back as top killer among women. Sushmi Dey; 2016. Available from:
. [Last accessed on 2017 Nov 18].
Jeronimo J, Castle PE, Temin S, Denny L, Gupta V, Kim JJ, Luciani S, et al
. Secondary Prevention of Cervical Cancer: ASCO Resource-Stratified Clinical Practice Guideline. J Glob Oncol. 2016; 12:635-57.
Goldie SJ, Gaffikin L, Goldhaber-Fiebert JD, Gordillo-Tobar A, Levin C, Mahé C, et al
. Cost-Effectiveness of Cervical-Cancer Screening in Five Developing Countries. N Engl J Med 2005; 353:2158-68.
Singhal T. Indian Academy of Pediatrics Committee on Immunisation (IAPCOI)-Consensus Recommendations on Immunization 2008. Indian Pediatr. 2008; 45:635-48.
Montgomery MP, Dune T, Shetty PK, Shetty AK. Knowledge and Acceptability of Human Papillomavirus Vaccination and Cervical Cancer Screening among Women in Karnataka. Indian J Canc Educ. 2015;30:130-7.
Burd EM. Human Papillomavirus and cervical cancer. Clin Microbiol Rev. 2003;16:1-17.
Kishore J, Mundra V Grewal I. Perception and use of pap smear among medical personnel in New Delhi, India. Health and Population: Perspectives and Issues. 2009; 32(3):141-7.
Jain SM, Bagde MN, Bagde ND. Awareness of cervical cancer and Pap smear among nursing staff at a rural tertiary care hospital in Central India. 2016; 53(1):63-6.
Gajalakshmi CK, Krishnamurthi S, Ananth R. Cervical cancer screening in Tamilnadu, India: a feasibility study of training the village health nurse. Cancer Causes Control. 1996;7:520-24.
Madhivanana P, Krupp K, Yashodha MN, Marlow L, Klausner JD, Reingold AL. Attitudes toward HPV vaccination among parents of adolescent girls in Mysore, India. 2009; 64:69-74.
LaMontagne DS, Barge S, Le NT, Mugisha E, Penny ME, Gandhi S, et al
. Human Papillomavirus Vaccine Delivery Strategies That Achieved High Coverage in Low- and Middle-Income Countries. Bull World Health Organization. 2011;89:821–30B.
Basu P, Sarkar S, Mukherjee S, Ghoshal M, Mittal S, Biswas S, Mandal R, Sankaranarayanan R. Women's perceptions and social barriers determine compliance to cervical screening: Results from a population based study in India. Cancer Detect Prev. 2006; 30(4):369-74.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]