Parents' Knowledge, Beliefs, and Acceptance of the HPV Vaccination in Relation to Their Socio-Demographics and Religious Beliefs: A Cross-Sectional Study in Thailand

Thailand has one of the world's highest prevalence of cervical cancer, mainly caused by the human papillomavirus (HPV). In Thailand, the HPV vaccine is available at a cost but not included in the national vaccination programme; parents must give consent to have their children be vaccinated, and their beliefs are important for successful implementation. This is a Buddhist country, and religion has a substantial impact on the healthcare system and regulations, cultural norms, and individual health beliefs. Thus, the aim of this study was to examine parents' knowledge, beliefs, and acceptance of HPV and the HPV vaccine for their young daughter/s, in relation to their socio-demographics, health behaviour, and religious beliefs in the Thai setting.

Studies undertaken in different contexts around the world show that parents' knowledge about HPV and the HPV vaccination is low overall. Positive parental beliefs and attitudes are important predictors of getting the HPV vaccination. On the other hand, reasons as to why parents are reluctant to give consent for the vaccination include concerns about side effects and long-term safety of the vaccine, insufficient information prior to making informed consent, the daughter's young age, and low perceived risk of getting an HPV-infection or HPV-related cancer. Lower socio-economics (education level and income) correlate with lower HPV vaccine uptake. Cultural norms, moral values, and religious beliefs are other factors associated with the decision on whether or not to get the HPV vaccination.

The theoretical framework used in this study is the Health Belief Model (HBM), which includes these central constructs: perceived benefit, perceived barriers, perceived susceptibility, perceived severity, and cues to action. According to the HBM, a person's health behaviour can be explained by the individual's beliefs regarding the health action. Knowledge and socio-demographic variables such as age, sex, religion, and ethnicity as well as the education level and income are modifying factors for the individual behaviour. Moreover, it is important for a person with risk behaviours to recognise the risk in order to be able to change his or her behaviour. The benefits have to outweigh the barriers for a person to act upon the health promotion - for example, participating in a screening (cervical cancer) or vaccination programme.

The researchers used a cross-sectional approach; thus, this design cannot provide information about causality regarding the relation between parental attitudes, beliefs, behaviour, knowledge, or acceptance of the HPV vaccination. Parents of 9- to 12-year-old daughters in 3 schools - 1 in Nakorn Phatom province (suburban) and 2 in Bangkok (urban) - completed the self-reporting questionnaires, guided by the HBM. In total, 359 parents completed the questionnaires; of those, 301 were included in the final analyses. Almost all of the included parents (99%) were Buddhists, and the majority (80%) of the participants were the daughter's mothers. Almost 40% of the participating mothers had never undergone a cervical cancer screening test (Pap smear).

The majority (76%) reported that their daughters had received (all or some) of the recommended childhood vaccinations. For background knowledge about HPV and the HPV vaccine, 52% and 46% reported that they had heard of or been informed about HPV and the HPV vaccine, respectively. The information channel included friends/family, media/advertisement, and healthcare professionals. ("Information about the HPV vaccine might be a trigger, cues to action, for the individual health behavior; thus, healthcare professionals' recommendations are important for making a decision about the HPV vaccine.") On a scale from 1 to 5, the mean of acceptance of the HPV vaccine was 3.52, which indicates that the respondents, on average, had a high acceptance of the HPV vaccine for their daughters. For beliefs, the means of susceptibility and severity were 3.42 and 3.83, while the means of benefits and barriers were 3.41 and 3.14, respectively. For knowledge, the mean was 3.96. This reflects that the respondents, on average, had around 4 correct answers out of the 14 true or false question items regarding HPV and cervical cancer.

In summary, the results showed that parents with greater knowledge of HPV perceived: a higher susceptibility for contracting HPV, HPV as being more severe, and more benefits about the vaccines protective effect against cervical cancer. Moreover, parents with greater knowledge had higher acceptance of the vaccine. There were also differences in knowledge due to the socio-demographic variables; parents in the higher-income group had greater knowledge of HPV and the HPV vaccine compared to parents in the lower-income bracket. In contrast to the researchers' hypotheses, parents who had a lower income perceived more benefits compared to parents with a higher income. Finally, parents who reported religion as being more important perceived higher susceptibility for an HPV-infection or cancer and perceived more benefits with vaccination against HPV. "It is probable that those parents who reported religion as being of importance have a strong belief in 'Karma' i.e., the misfortune, good or bad things that happened in life are the result from the previous life, which they cannot control so that the risk of cancer can be real and the vaccine will help to resolve it."

The researchers stress that "[b]ackground knowledge of the HPV vaccine was positively related to acceptance, indicating the importance of parents having knowledge about the vaccine before implementation. The acceptance of the HPV vaccine was high among the included parents. The majority had accepted previous childhood vaccinations, which is important since vaccine hesitancy is a growing challenge globally....Research shows that acceptance of previous childhood vaccinations is associated with parental acceptance of the HPV vaccination....Thailand has high coverage of childhood vaccinations, and countries with well-functioning national vaccination programs, especially countries with school-based vaccinations, have a higher coverage of the HPV vaccination."

In conclusion: "Acceptance of the vaccine was high, and we believe our results are promising for future implementation of the HPV vaccination in the national childhood vaccination program in Thailand."