Awareness, Perceptions, and Choices of Physicians Pertaining to Human Papillomavirus (HPV) Vaccination in India: A Formative Research Study

"Findings from the study will inform the design of interventions aimed at supporting physicians with making HPV vaccine recommendations routinely and strongly to parents of adolescent girls."

A vaccine to prevent human papillomavirus (HPV) infections, the primary cause of cervical cancer, is available in India, but multiple barriers lead to its low uptake. As India prepares to add the HPV vaccine to the national immunisation programme, the country is considering factors that can be modified to impact uptake. One such factor, as shown in previous research, is patient-physician communication. Thus, the goal of the study was to understand the variation in awareness, perceptions, and choices of physicians when recommending the HPV vaccine to parents of adolescent girls in West Bengal, India.

The research was part of a larger study guided by the socioecological theory of behaviour, which posits that individual behaviour is influenced not only by individual characteristics, perceptions, and resources, but also by contextual factors and processes. This manuscript focuses solely on the findings from physicians in order to highlight the untapped opportunity physicians provide in increasing vaccine rates.

Between July and August 2019, the researchers carried out qualitative in-depth interviews with 32 physicians in Howrah and Kolkata, which are characterised by low immunisation rates. When initially screened, the majority of the participants were identified as generally favourable towards the HPV vaccine (78%) followed by generally unfavourable (13%) and unsure or having mixed feelings (9%). Most were male (63%).

The findings suggest that while physicians are generally aware about the burden of cervical cancer and its prevention by HPV vaccination, they reported a lack of awareness about cervical cancer among patients, in the community, and among physicians serving rural communities, in particular. When the HPV vaccine was first launched in the country, physicians reported that they had questions about the effectiveness, efficacy, age group, impact on adolescent girl's fertility, dosage, cost, and side effects, among others.

Physicians reported that most discussions about cervical cancer were initiated by them, indicating they face several barriers to recommending the HPV vaccine routinely and strongly. Challenges include the lack of national-level guidance on the age eligibility and dosage, lack of practice-level opportunities such as well or non-sick visits and other routine adolescent vaccines, practice-level barriers like out-of-pocket cost and vaccine availability, and perceived parental hesitancy arising from reluctance to discuss cervical cancer, its prevention, and HPV vaccination.

This study suggests that:

• Physicians need more reassurance and clarity on why the HPV vaccine is most effective at early ages, its safety, and on how to communicate concisely to parents. For instance, physicians may benefit from more training and resources on how to discuss HPV vaccination as a means for cervical cancer prevention and to address standard parental questions or concerns confidently.
• Engaging and persuasive interventions that are evidence-based could be particularly useful to support physicians in making a high-quality recommendation of the HPV vaccine to parents of adolescent girls in India.
• There are opportunities to strengthen and unify policies and guidelines on HPV vaccination in India to address logistical issues such as cost and availability.

In conclusion: "It is important that the barriers pertaining to when and how physicians recommend the vaccine be tackled through further education, policy change, and development and implementation of interventions that are evidenced-based."