Introduction: Cervical cancer causes major morbidity and mortality around the world. This makes prophylactic vaccines a significant tool for preventing the disease. As these vaccines become more widely available, they have the potential to drastically lower the cancer’s prevalence and burden in the future.

Aim: The aim of this study was to assess the attitudes toward awareness of the human papillomavirus (HPV) vaccination.

Materials and methods: A pilot, cross-sectional, medicosocial survey was conducted using a structured, anonymous online questionnaire, including self-assessment questions on awareness and attitudes towards HPV vaccination. Sixty-four adult female parents of female children participated in the study between June and August 2023. The design and conduct of the study was done with the personal involvement of the researchers. SPSS v. 23.0 was used to analyze the primary statistical information. The results obtained were presented graphically using MS Excel 2010.

Results: We found significantly good awareness and negative attitude towards vaccination as prevention against HPV.

Conclusion: The present study demonstrated that respondents had a relatively good awareness of cervical cancer, the risk factors associated with the disease, and the virus that causes it. There was a correlation between socio-demographic characteristics and awareness of the study population. The respondents had a certain distrust of the vaccine. The dissatisfaction stemmed from the fact that vaccination was not a substitute for routine cervical screening, was not 100% effective, and did not provide protection against any type of papilloma virus or against pre-existing HPV infections.

The low vaccination coverage in Bulgaria leads the authors to believe that our country urgently needs new strategies and approaches in the fight against cervical cancer, through continuous training of medical personnel, inclusion of immunization programs in school health care, and improved health education and awareness of HPV vaccination among adolescent girls and their parents.

awareness, HPV, immunization, prevention, primary prevention

Human papillomavirus (HPV) can cause cervical cancer, genital warts, oropharyngeal cancer, anal cancer, and various cancers of the vulva or vagina.^[1]

Cervical cancer is a serious disease that affects thousands of women worldwide. Thanks to the advances in medicine and based on research into this socially important pathology, a vaccine has been developed to prevent the disease from occurring. European guidelines focus on quality primary HPV testing, the organization of HPV-based and cytology screening programs and the implementation of vaccination programs against the papilloma virus. Countries with cervical cancer screening and prevention programs have seen reduced morbidity and mortality caused by this pathology.^[2]

HPV infection is common, sexually transmitted, with infection with the virus usually occurring soon after first sexual contact.^[3] In their study, Sandeva and Kuzmanov concentrated on the sexual behavior of a group of students and showed that sexual life begins relatively early, at around the age of 15, and that a significant percentage of girls engage in high-risk sexual behavior, which is a requirement for unintended pregnancy, STDs, HPV infection, and the development of PMH at a later stage.^[4] Persistent infections with high-risk oncogenic HPV types 16 and 18 can lead to the development of cervical cancer, even after several decades. Many new HPV infections occur in adolescents, but they can also occur in sexually active adults exposed to the virus from a new sexual partner.^[1] Establishing a causal link between papillomavirus infection and cervical cancer is considered one of the most significant scientific advances that makes prevention of these cancers possible through vaccination.^[5]

HPV vaccination is most effective when administered before exposure to HPV, and in early adolescence. Young girls remain the most important focus of the HPV vaccination program^[1], and their parents should be targeted by public programs to raise awareness and create positive attitudes towards vaccinating their children.

Worldwide, a number of studies have focused on the attitudes and awareness of HPV and its associated viral load. These studies have found a low level of knowledge in the population regarding this pathology and the risk factors leading to the disease, which is a barrier to screening.^[6] The authors recommend primary prevention of this type of cancer among schoolchildren.^[7]

A report by the European Federation of Pharmaceutical Industries and Associations (EFPIA), developed by several international organizations, states that Bulgaria is at a critical level of HPV vaccination, despite the reimbursement since 2012. The reason for this, according to the authors of the report, is the lack of a national cancer control plan, as well as immunization programs in schools, while some European countries have successfully implemented such programs. There are after-school immunization programs in our country. Bulgaria’s inequity in the access to biometric testing and new, modern treatments in oncology can be corrected through new strategies and approaches to the fight against cancer, innovations in diagnosis and treatment, ongoing training of medical professionals, improved health literacy, and awareness of the benefits of HPV vaccination.^[8] Vaccination uptake in Bulgaria is alarmingly low, so it is important to assess the attitudes and awareness of human papillomavirus (HPV) vaccination in order to support the development of strategies aimed at increasing vaccination uptake in the Bulgarian population.

The aim of this study was to assess the attitudes and awareness of the human papillomavirus (HPV) vaccination.

A pilot, cross-sectional, medicosocial study was conducted using a structured, anonymous online survey, which included questions on self-assessed awareness and attitudes towards HPV vaccination.

The questionnaire consisted of 19 open and closed questions grouped into two sections:

• First section – Socio-demographic characteristics of the contingent: contains 5 questions
• Second section – Attitudes and awareness of cervical cancer, the causative agent (HPV), risk factors, fear of infection and questions about the vaccine: contains 14 questions

Sixty-four adult women, parents of female children, participated in the survey which was performed between June and August 2023. The survey design and conduct was done with the researchers’ personal involvement.

The signs of observation were divided into the following groups:

Factorial: age, residence, education, marital status, and employment.

Resultant: awareness of human papillomavirus, cervical cancer and risk factors that cause it, HPV vaccine, attitudes about papillomavirus infection, awareness and attitudes about HPV vaccination.

According to the purpose of the study, the size and type of data, the following statistical methods were used:

• Descriptive statistics – to process quantifiable attributes.
• Alternative analysis – to summarize qualitatively measurable dichotomous data: estimation of relative proportion in percentages.
• Parametric analyses: T-test for two independent samples (independent sample t-test): the test for statistically significant differences between two means.
• Non-parametric analyses: the Mann-Whitney and Kruskal-Wallis methods when examining rank quantities defined by five-point Likert scales and when examining metered quantities that do not have a normal distribution.

MS Excel 2010 was used to illustrate the observed processes and phenomena and to illustrate existing patterns.

The critical level of significance used was α=0.05.

Data analysis was performed using IBM SPSS Statistics v. 23.

By tracking the attitudes and awareness of respondents in our survey, we sought to ascertain their attitudes towards the HPV vaccine regarding cervical cancer (CC) and the risk factors associated with the disease and the virus that causes it.

Seng et al., in a study about awareness of cervical cancer (CC) among women in Malaysia, found a lack of knowledge and information about CC among the study group. Insufficient communication by а health-care professional, leading to low attendance of women and low awareness of СС, is believed to be the cause.^[9] In our study, the relatively high proportion of informed respondents about cervical carcinoma (70.32%) and risk factors leading to it (71.88%) was evidently reported.

Abduxike et al., in a cross-sectional study assessed parental knowledge and awareness of papillomavirus and related diseases, and the effect of HPV vaccines. The study found good awareness of the virus, associated diseases and the vaccine. The authors concluded that the implementation of awareness campaigns significantly influenced parents’ opinions about the uptake of the HPV vaccine as prevention against cervical cancer.^[10] This underscores the importance of our study in assessing attitudes and awareness about HPV, which can help inform government strategies to promote vaccination against the papillomavirus.

From the results obtained, the respondents’ awareness proved to be relatively good, while Mbulawa et al. in their study on knowledge of HPV in South Africa, demonstrated low levels of knowledge and awareness of the disease, among the female and male South Africans they surveyed. The authors found that younger, more educated, higher-income family respondents were more familiar with the problem, while knowledge was limited in rural areas. This calls for health promotion strategies that will benefit all genders in the future.^[11] Our data corroborate the results of Mbulawa et al. – awareness, regarding cervical cancer and the risk factors associated with the disease and the virus that causes it, decreases with increasing age. In contrast to their study, we also found a statistically significant association between awareness of risk factors leading to malignancy of cervix uteri and marital status. We did not find any association between the studied factor and the residence, education or employment of the study group.

According to one of the studies regarding knowledge of HPV, the causative agent of cervical cancer, and vaccination, conducted among a group of nursing students in Saudi Arabia, Abdelaliem et al. found low levels of knowledge of HPV, and moderate attitudes towards vaccination against the virus itself. The study suggests that additional measures such as curriculum adjustments and curriculum activities need to be incorporated. Clinicians’ recommendations play an important role in the parents’ decision to vaccinate their children against HPV.^[12] The present results of our study contradict the study of Abdelaliem et al. We proved that respondents were relatively familiar with human papillomavirus (HPV) and found a statistically dependent relationship between the studied indicator and the age of respondents.

The relatively high results obtained by the respondents regarding the threat and fear of infection with human papillomavirus (HPV) can be linked to a study by Qaderi et al. The authors followed Iranian women’s psychological reactions to a positive HPV test result. The initial reactions the authors found to positive HPV results were shock, unrealistic fear, confusion, distress, and financial concerns. The fears of partner infection indicated that women consider HPV to be more than just a cause of cervical cancer.^[13]

Respondents’ positive attitudes about vaccination are likely motivated by the fact that the combination of HPV vaccination and cervical screening may provide the best protection against cervical cancer. Vaccination against human papillomavirus also reduces the risk of developing cancer at sites other than the cervix.

In a meta-analysis of vaccination programs covering girls in 14 high-income countries with substantial vaccination coverage, the number of anogenital warts among women aged 25-29 years was shown to have largely declined over the 8-year period since vaccination began, with a slightly higher proportion among boys (48%) aged 15-19 years, and among men (32%) aged 20-24 years, compared with the pre-vaccination period.^[14]

Another study conducted in the USA in women aged 20-29 years found that over a 10-year period after vaccination, there was a significant decline in the prevalence of HPV types among vaccinated and unvaccinated populations, confirming direct and group herd protection.^{[14, 15]} A correlation was found between susceptible individuals and immunized ones, in which the risk of infection decreased.‌^[16] From the results of our study, we found that a relatively high proportion (60.94%) of respondents confirmed their knowledge of the vaccine’s benefit. They obtained their information mainly from specialized literature and the internet, which is in contrast to the results of the study by Tapera et al. on knowledge, attitudes and practices regarding cervical cancer, its prevention and treatment. They found that knowledge of the causes and prevention of cervical cancer was associated with frequent radio listening, making a recommendation on the need for increased health education through telephone messages, communication with health workers and various media campaigns among the community in Harare, Zimbabwe.^[17]

In a study by Gamaoun on awareness and knowledge of cervical cancer methods and prevention among a group of 500 Tunisian women, a relatively high proportion of positive attitudes towards the HPV vaccine (over 80%) and a lower proportion (about 40%) of those informed about papillomavirus infection and the disease it causes were found.^[18] In our study, the results revealed that vaccination as prevention against HPV is not co mmon among the Bulgarian population, despite the positive attitude of the respondents about vaccination. This proves the low vaccination activity in our country.

More than 12 years of monitoring the safety of vaccination show that vaccines have not caused serious adverse reactions^[19], but more than a third of the Bulgarian women surveyed are reserved about vaccination precisely because they believe that there are side effects. The most common problems were short-term soreness and other local symptoms at the injection site.^[20] These problems are similar to those usually encountered with other vaccines. Although the safety of the HPV vaccine has been established, even when administered to people who are already infected with HPV, the maximum benefit of vaccines has been shown to occur before individuals are sexually active.^[21]

In an analysis of parents’ attitudes and knowledge about the cervical cancer vaccine and the factors influencing their choice of whether to vaccinate their children in Kaunas, Lithuania, Zastavna et al. concluded that the driver for a successful vaccination program is parental awareness of the risk of HPV infection, vaccine safety, and “regularity and transparency of adverse effect monitoring.” In the authors’ study, they found that the most common reason for vaccine distrust was impaired sexual activity in children, and the motivation among parents was mainly due to the risk of possibly developing cervical cancer.^[22] This differs from our results in which the most common reason for distrust of the vaccine was fear of side effects (35.94%).

Public distrust and criticism of HPV vaccination has increased significantly in Europe in recent years, with recommendations aimed at providing more information related to vaccine safety and rebuilding trust in health workers and authorities. Karafilakis et al. pointed out in their study that a large proportion of respondents linked their fears to lack of information and fear of vaccine side effects. Our study found that more than half of the respondents (60.94%), experienced some distrust towards the vaccine, and a difference of opinion among respondents regarding the need for more information. The same findings were found in a study by Karafilakis et al. on the trust in the HPV vaccine in a number of European countries. Very low vaccination rates were shown to be associated with a lack of trust. The researchers conclude that the skepticism about the vaccine can be eliminated by including more information campaigns focusing on the effectiveness and side effects of the vaccine, maintaining trust in health authorities and institutions to prevent more cases of mistrust.^[23]

Khan et al. reported that for several decades the burden of HPV-related malignancies has been increasing at an alarming rate due to lack of adequate awareness and vaccine coverage. With the advent of new treatment related technologies pertaining to therapeutic interventions and use of effective vaccine coverage, the burden of this disease can be reduced in the population.^[24]

A comprehensive HPV vaccination program has the potential to reduce the incidence of CC among girls and women by up to 90% worldwide.^[21] In addition, vaccines can reduce the need for screening and follow-up medical care, biopsies, and invasive procedures associated with follow-up from abnormal cervical screening, thereby helping to reduce healthcare costs and concerns associated with follow-up procedures. There is a need to raise awareness among respondents about the problem of human papillomavirus (HPV) and vaccination against HPV infection.

The present study found a relatively good awareness among the respondents about cervical cancer, the risk factors associated with the disease and the virus that causes it.

There is some hesitation related to the fact that the vaccine does not provide protection against all types of HPV infections, they are not aware of its side effects, it has not been proven to cure but only as a prophylaxis against infection with the virus, without replacing routine screening.

Vaccination activity in Bulgaria is very low. This gives the authors reason to believe that our country urgently needs new strategies and approaches in the fight against cervical cancer, through continuous training of medical personnel, inclusion of immunization programs in school health care, and improved health education and awareness of HPV vaccination among adolescent girls and their parents.