Lack of knowledge and awareness on cervical cancer vaccination hinders the administration of HPV vaccination among the health care professionals.

Background: Cervical cancer is the second most common cancer among females in India. This study was conducted regarding current awareness about cervical cancer, which is helpful in designing educational programs and to overcome barriers associated for knowledge enhancement about cervical cancer and its screening & vaccination. Methods : This is a cross-sectional study conducted among 318 health care professionals working in tertiary hospitals across Chennai, Tamil Nadu, India. A semi-structured questionnaire with 31 items was developed by the researchers to explore the knowledge and attitudes on cervical cancer, cervical cancer prevention and HPV(Human Papilloma Virus)vaccination. Results: Among the 318 respondents, 90.6% were aware of cervical cancer, but only 29.2% had done screening against cervical cancer and 19.8% got vaccinated. 94.7% of the study subjects heard of HPV and 86.2% knew that HPV causes cervical cancer. 83.3% people knew that PAP( Papanicolaou) smear test detects the cervical cancer. But, only 29.2% had PAP test. 68.2% of the study subjects knew that cancer cervix can be prevented by vaccination. But only 19.8% got vaccinated .Only 34.9% know that HPV vaccine can be given to boys. Most common reason for not getting vaccination was lack of awareness. 77.2% in our study are willing for vaccination and recommendation to their friends and family members. Conclusion: Lack of awareness with regard to the cervical cancer could be the possible hurdle for the HPV vaccination among the health professionals.


Introduction
Cervical cancer is the second most common cancer among women worldwide. 1In India, most of the cervical cancer cases are diagnosed in advanced stage reducing the survival rate of women with cervical cancer.The main reason for the late stage diagnosis is due to lack of awareness about screening and preventive methods of cervical cancer. 2man papillomavirus (HPV) infection is the cause of cervical cancer, particularly HPV 16 and 18 strains causes 75% of cervical cancers world wide. 3Other risk factors include having multiple sexual partners, early age of sexual intercourse, tobacco consumption, prolonged use of oral contraceptive pills, increased parity, and early age of giving birth. 4Most of the Genital HPV infections are asymptomatic but evidence show that nearly all cervical cancer cases are caused by high-risk HPV types. 5Screening with Pap test or VIA, or application of effective HPV-DNA detection procedures, precursors of cervical cancer can be easily detected and successfully treated at an early stage.Thus, effective screening reduces cervical cancer can be easily prevented with regular screening programmes.Screening the women for cervical cancer is essential as the women often do not experience symptoms until the disease has advanced. 5The prevention and control of cervical cancer depend on awareness about disease, screening procedures, and preventive measures. 4Two vaccines Gardasil & Cervarix are available in India which are licensed globally. 6The vaccine dose is 0.5 mL given intramuscularly at 0, 2 and 6 months are recommended with Gardasil or 0, 1 and 6 months with Cervarix. 7,8The recommended age for vaccination is 9-12 years.Catch-up vaccination is permitted up to the age of 26 years.Vaccine was approved for administration to boys between the ages of 9 and 26 years in developed countries. 7The vaccine is not recommended for use in pregnant women. 7,9Lactating women can also receive the vaccine.The vaccine was approved for administration to males between the ages of 9 and 26 years in developed nations. 7,9nce, this study was conducted regarding current awareness about cervical cancer, which is helpful in designing educational programs and to overcome barriers associated for knowledge enhancement about cervical cancer and its screening & vaccination.

Measures:
The semi-structured questionnaire was developed by the researchers consists of thirty one questions/statements on demographic characteristics & information pertaining to the cervical cancer preventive methods.The socio demographic variables embrace Age, Gender, Profession, Educational Quali cation, good Experiences, legal status, no of youngsters, and case history of Cervical Cancer.The demographics were followed by the questions/statements related to the knowledge on Cervical Cancer, preventive methods of cervical cancer and knowledge on HPV vaccination.For data collection through this survey on a 3 point Likert scale, the respondents have to record their response on the 3 point Likert scale ranging from: Yes/No/I don't know.The survey consists of one question aimed at exploring the plausible reasons reported for not administration of HPV and the respondents were instructed to record their choices (more than one reason) from pre-determined 6 choices/reasons (Lack of awareness/High cost/Fear of side effects/Doubt on e cacy/Lack of interest/Do not know the importance of the administration of HPV vaccine).

Statistical Analysis:
All the categorical variables are presented as numbers or percentages.Descriptive analysis was performed using univariate statistics to report the Mean and Standard Deviation (SD) for the continuous variable and frequency distributions for the categorical variables.Correlation, T-statistic and Analysis of Variance (ANOVA) were performed to compare differences in the continuous variables.Pearson chisquare test was used to identify the differences in distribution.The relationship between preventive behaviors (i.e., Pap test or HPV vaccination) against cervical cancer and related factors (such as age, profession, marital status, Number of children, Family history of cervical cancer and knowledge of cervical cancer) was evaluated using logistic regression analysis.Odds ratios (ORs) and 95% con dence intervals (CIs) were also calculated.

Discussion
Cervical cancer remains the most common cancer among the women inspite of advances in prevention and treatment.Our study found that majority of the participants were aware of cervical cancer.But only 29.2% had done screening against cervical cancer and 19.8% got vaccinated.In our present study, 90.6% were aware of cervical cancer which is better than other studies. 9,10When asked about the HPV 94.7% of the study subjects said they have heard of it and 86.2% knew that HPV causes cervical cancer which seems to be better than a similar study in which only 73% study subjects heard of HPV. 9 2][13] But only 29.2% had PAP test in our study but it was only 5% in few studies. 14,15This shows that we lack an organized opportunistic screening program for cervical cancer in India.It is essential to screen all eligible women when they visit health care units for other services.68.2% of the study subjects knew that cancer cervix can be prevented by vaccination.But only 19.8% got vaccinated which was higher when compared with studies by Swarnapriya et al 16 and Sunite GA et al 17 where vaccination coverage was 6.8% and 5.5% respectively.In contrast, 26.73% of them were vaccinated in a study conducted by Hoblidar S et al. 18 This is because Indian parents are less interested in vaccinating their children and hence the vaccine coverage in the target population is not up to the required level.There is a need for educational programms regarding screening and vaccination to reduce the disease burden.Only 34.9% know that HPV vaccine can be given to boys.In developing countries like India, administration of HPV vaccine to the boys was not practised, so this could be the reason for lack of awareness that HPV can be given to boys which is re ected in our study.
Most common reason for not getting vaccination reported in our study was lack of awareness which is in similarity with other studies. 18In contrast, high cost of the vaccine was the most common reason reported for not being vaccinated. 19Various studies have reported that people with family history of genital cancer had shown greater acceptability for vaccination against HPV. 2077.2% in our study are willing for vaccination and recommendation to their friends and family members which is in contrast with other studies in which they were not keen on getting vaccinated. 16e profession, knowledge on cervical cancer, HPV, screening, availability of vaccine associated(statistically signi cant association) and have a negative effect on administration of HPV vaccination.Knowledge on HPV vaccine to pregnant women associated and have a positive effect on HPV vaccination.When combined together all the variables, only the knowledge of the HPV vaccination in pregnant women was positively associated with decision to administer the HPV vaccine or recommend the administration of HPV vaccination to the family/friends.
There is a large gap which has to be lled to improve the awareness about HPV vaccination.This requires that every child needs to be vaccinated and every mother needs to be screened.This kind of interactive and informative session helps in developing a positive attitude towards vaccination screening.Medical colleges need to be focussed as an academic curriculum on screening and vaccination to motivate the society towards vaccination as they are the primary source of information.

Conclusion
By virtue of our ndings in this present study, it is evident that lack of awareness with regard to the cervical cancer could be the possible hurdle for the HPV vaccination among the health professionals.
This clearly establishes the need to devise intervention programmes to educate the healthcare professionals on the cervical cancer and more importantly the importance of the administration of the HPV vaccine, that improves the quality of women wellbeing.
-Consent for publication: All authors provided their consent for publication of this manuscript.
-Availability of data and material: The data used to support the ndings of this study are available from the corresponding author upon request.
-Competing interests: "All the authors declare no con of interest." -Funding: "This research received no external funding".
-Authors' contributions: SM, PC, SKM: having contributed equally to the work; DR, GB, PS, UMC, KMJ: contributed to data curation, validation, visualization and writing the manuscript; BP, SRTK, CPA, PP: contributed to formal analysis, validation, visualization and writing the manuscript; SM, PC, DR, GB, PS, BP, UMC, KMJ, SRTK, CPA, PP & SKM: All authors reviewed the manuscript and approved the submitted manuscript. -Acknowledgements: We are thankful to Dr. S. Porchelvan, MSc, MBA, PGDCA, PhD, Professor in Biostatistics for assisting with the statistical analyses.
-Author's Information: Study Participants: A Cross-sectional study was conducted in Panimalar Medical College Hospital & research Institute, Varadharajapuram, Poonamallee, Chennai, Tamil Nadu, India.A random sample of 318 health care professions working in tertiary hospitals in Chennai, Tamil Nadu, India.Those participants who were above 18 years of age and who are willing to give their consent to participate in this study have been included.Informed consent has been obtained from all the participants.The study protocol was approved by the Institutional Review Board (IRB) of the Panimalar Medical College Hospital & Research Institute, Chennai (Panimalar Medical College Hospital & Research Institute IRB #1/2020/005) and conformed to the requirements of the Declaration of Helsinki (as revised in Seoul 2008).

Table 1 :
All statistical analyses were performed using Statistical Package for Social Science (SPSS, version 17) for Microsoft windows, SPSS Inc. USA.Results 90.6% of the participants were aware of cervical cancer.But only 29.2% had done screening against cervical cancer and 19.8% got vaccinated.94.7% of the study subjects have heard of HPV and 86.2% knew that HPV causes cervical cancer.Demographic characteristics of the Health Care Professional included in the study (N=318) 83.3% people knew that PAP smear test detects the cervical cancer even before the symptoms appear, but only 29.2% had PAP test.68.2% of the study subjects knew that cancer cervix can be prevented by vaccination.But only 19.8% got vaccinated Only 34.9% know that HPV vaccine can be given to boys.Most common reason for not getting vaccination reported in our study was lack of awareness.77.2% in our study are willing for vaccination and recommendation to their friends and family members.Table:1 it shows the socio demographic characteristics of the health care professionals.

Table 2 :
Knowledge towards cervical cancer among health care Professionals enclosed within the study

Table 3 :
Knowledge towards HPV & HPV Vaccination among health care Professionals enclosed within the study (N=318)

Table 4 :
Odds ratio and 95% con dence intervals of family members vaccinated for human papilomavirus vaccination according to selected variables among health care professionals included in the study (N=318)