The Impact of Health Education Interventions on HPV Vaccination Uptake, Awareness, and Acceptance among People under 30 Years Old in India: A Literature Review with Systematic Search

"Observations from this study outline immediate action for policymakers to educate and encourage the young population toward HPV vaccination."

Indian society is highly patriarchal, leading to health inequalities for women. For example, the overall shame associated with women's sexual activity carries over to sexually transmitted infections (STIs), including human papillomavirus (HPV). HPV vaccination uptake in India is low due to discouraging cultural perceptions of vaccines, misinformation regarding safety and effectiveness, and cost. In July 2022, the Drugs Controller General of India (DCGI) authorised an indigenous quadrivalent vaccine. In light of the role health education will play in India's HPV vaccination strategy, and yet considering its conservative culture, this systematic review examines the effectiveness of health education among Indians aged 9-29 years.

Research was performed in the following databases: PubMed, CINAHL, Scopus, and Embase to identify studies between 2008, when the HPV vaccine was first licensed in India, and July 13 2022. Of the 10,952 results, 7 studies were included. Four studies focused on adolescent girls; 3 focused on university students. Health education interventions reported in the studies involved audio-visual presentations, lectures, sensitisation sessions, and a community-based approach using tools such as training, community-based workshops, and leaflets.

The participants had the opportunity to receive the HPV vaccine following the health education intervention in only 3 studies. In a study implemented in a college in Bhubaneswar, although 86% of the girls agreed to receive the vaccine, only 58.33% actually received their first dose. In Sikkim and rural West Bengal, the uptake among adolescent girls was reported to be above 95%. In Sikkim, the success was described as being multifactorial in that it featured the involvement of several stakeholders such as religious and political leaders, doctors, and parents. Moreover, this HPV vaccine introduction programme included a variety of different educational materials, depending on the intended group.

Poor awareness was reported to be common prior to interventions, especially among the general population. All the studies that reflected on the knowledge of the participants after the intervention reported an improvement in their knowledge. Overall, female participants demonstrated greater acceptance and awareness compared to men.

A major gap both in research among gender and marginalised young population groups (illiterate, rural area residents) and in the application of health education interventions was identified. The research also identified a lack of studies of HPV vaccine health education conducted in neighbouring countries such as Sri Lanka, Nepal, and Bangladesh, which highlights the need for development of evidence-based strategies in South Asia.

It is recommended that future programmes involve several stakeholders and use a variety of educational methods according to the population group (e.g., parents, students), the settings (e.g., community-based), and the limitations of the programme (e.g., during a pandemic). Considering that the main population group constists of students, it is advised that HPV vaccine information be part of the curriculum of health education in schools. Moreover, since awareness appeared to be inadequate among university students, health education and opportunistic vaccination could be part of the university's curriculum by organising workshops, thematic days, etc.

In rural areas, where cancer prevalence is higher due to a variety of factors such as illiteracy, poor hygiene, and early marriage, the role of Accredited Social Health Activist (ASHA) workers could be expanded by adding HPV vaccination counselling. However, before extending the role of ASHAs, it is crucial to apply strategies for narrowing the gap between knowledge and practice. In this case, health education is essential for two reasons: to provide knowledge to ASHA workers regarding HPV vaccines and screening and to help them improve their health promotion strategies.

Lastly, efforts out to be made to increase HPV vaccination rates among girls who do not attend school. In 2021, Holroyd et al. published research on designing a pro-equity HPV vaccine delivery programme for girls who dropped out of school in a community set-up in India. Their findings highlight the necessity of the parents' involvement and education and the importance of out-of-school accessibility. Their recommendations include, among others: the utilisation of media to spread awareness to low-literacy populations, the engagement of vaccinated girls, and the adjustment of the vaccination programmes to the needs of the intended populations.

In conclusion, this research demonstrated that "health education is an effective tool to improve awareness, uptake, and acceptance among the Indian young population....[I]t is critical that future health education interventions are inclusive and accessible to the whole population in India [including males and marginalised populations]. Policy-makers ought to take into account the individual characteristics of each target group and adjust communication interventions accordingly. The involvement of several stakeholders such as religious and political leaders proved to play a key role in the success of HPV vaccination strategies. Hence, it is recommended further programs include a variety of stakeholders as part of their communication strategy."