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Abstract

Background

Human papillomavirus (HPV) is known as a common agent of sexually transmitted infections and cervical cancer. One of the most effective ways for parents to protect their children from HPV is by ensuring they receive vaccinations.

Aim

To determine the percentage of parents who intend to vaccinate their children against HPV and associated factors.

Method

A cross-sectional study was conducted on 365 parents who had children attending high school in Ha Tinh province, Vietnam, from April to May 2023, using stratified and random sampling methods. Data were collected by a self-administered questionnaire designed based on previous studies and the domains of the Theory of Planned Behavior and Health Belief Model. A multivariable logistic regression was performed to determine the association between several factors and vaccination status.

Result

A total of 365 participants took part in the study. The rate of parents intending to vaccinate their children against HPV was 55.9%. Knowledge about the HPV disease and vaccine (all P < .05) and the attitude of parents (P < .001) were determined as the motivation factors that affect the intention to vaccinate children against HPV.

Conclusion

Many parents still do not have the intention to vaccinate children against HPV. Health education communication should focus on the motivation factors, not only to improve the parents’ knowledge and perspective but also to increase the coverage of the vaccine to prevent cancers caused by HPV.

Plain Language Summary

Background: Human papillomavirus (HPV) is known as a common agent of sexually transmitted infections and cervical cancer. One of the most effective ways for parents to protect their children from HPV is by ensuring they receive vaccinations. Aim: To determine the percentage of parents who intend to vaccinate their children against HPV and associated factors. Method: A cross-sectional study was conducted on 365 parents who had children attending high school in Ha Tinh province, Vietnam in 2023, using stratified and random sampling methods. The data was collected by a self-administered questionnaire designed based on the previous studies, and domains of Theory of Planned Behavior and Health Belief Model. A multivariable logistic regression was performed to determine the association between several factors and vaccination status. Result: 365 participants took part in the study. The rate of parents intending to vaccinate their children against HPV was 55.9%. Knowledge about the HPV disease and vaccine (all P < .05), and the attitude of parents (P < .001) were determined as the motivation factors that affect the intention to vaccinate children against HPV. Conclusion: Many parents still don’t have the intention to vaccinate children against HPV. Health education communication should focus on the motivation factors, not only to improve the parents' knowledge and perspective but also to increase the coverage of the vaccine to prevent cancers caused by HPV.

Keywords

human papillomavirus vaccine behavioral intention adolescent vaccination theory of planned behavior health belief model

Introduction

Human papillomavirus (HPV) is a common agent of sexually transmitted infections in both genders,¹ which can spread during sex or close skin-to-skin with the infected person who may show no symptoms.² HPV has many genotypes that cause warts or cancer of the cervix, anus, vulva, vagina, penis, mouth, and throat in people.² The person who has abnormal Pap tests (i.e., HSIL) and a positive test for HPV type 16 should be treated by electrosurgical excision procedure.³ According to the World Health Organization (WHO), cervical cancer is the fourth most common type of cancer among women globally, with approximately 640 000 new cases and 342 000 fatalities reported yearly.⁴ In 2020, around 90% of the new cases and deaths occurred in low and middle-income countries such as Vietnam.⁴ HPV is responsible for 4.5% of all cancer cases worldwide, with 630 000 new cases annually in both sexes, 8.6% in women and 0.8% in men.^5,6

Early administration of HPV vaccination before exposure to risk behaviors is considered a safe and effective measure to help prevent HPV- related diseases.⁷ Vaccines have been proven to prevent more than 90% of cancers caused by HPV.⁸ A previous study indicates that providing HPV vaccination to both boys and girls could more effectively eradicate HPV and reduce HPV-related diseases compared to vaccinating only girls.⁹ HPV vaccination rates are low in low- and middle-income countries. Only about 1% of girls aged 10 to 20 have received at least 1 dose of the HPV vaccine worldwide.¹⁰ In Vietnam, there are 3 approved and recommended HPV vaccines for children and women aged 11 to 26 years including Cervarix, Gardasil 4 and 9.

Sexual activities are prevalent among adolescents, increasing the likelihood of sexually transmitted diseases such as HPV without necessary awareness and protection.^11,12 Vaccination is one of the effective ways to ensure that young people are protected against HPV. Parents are the driving force for their children’s health, including receiving any vaccination. According to Ajzen’s Theory of Planned Behavior (TPB), the intention to vaccinate children against HPV may be based on attitude, perceived subjective norms, and perceived behavioral control toward HPV and vaccines, which helps to predict future parental behavior regarding HPV vaccination for their children.¹³

The previous studies in Vietnam indicated that the percentage of parents’ intention to vaccinate against HPV is relatively low, ranging from 49.2% to 53.6%.^14,15 Some studies have shown that Parents’ knowledge ^16-20 and attitudes^17,21-23 about HPV disease are associated with their children’s intention to get vaccinated against HPV. Other factors like age, marital status, and educational status of parents also contribute to the lack of HPV vaccination rates among young adults.^16,21,24 TPB and The Health Belief Model (HBM) show usefulness, reliability, and applicability in research on individual behavior; specifically, the parents’ intention to vaccinate their children against HPV.²⁵ Our study aims to investigate parents’ intention to have their children receive the HPV vaccine and identify methods to increase HPV vaccination rates among young adults.

Materials and Methods

Study Design and Sample Size

A cross-sectional study was conducted on parents with children studying at Nguyen Thi Minh Khai High School in Ha Tinh Province, Vietnam, from April to May 2023. The current investigation utilizes the single population proportion formula with a 95% confidence interval, 5% margin of error (d), and population proportion (P = .378) as an estimate of the percentage of parents who intend to vaccinate their children against HPV, as discussed by Jean-Francois Huon et.al.²⁶ The minimum sample is 362 parents. Predicting a 10% sample loss, we calculated the sample size as 403 parents. The stratified sampling method was utilized to specify the number of students from each grade. We determined 124, 137, and 143 students in 10, 11, and 12 grades, respectively. We then randomly sampled students to participate in the research. For each student, we contacted their parent to inform them about the research. If they agreed to participate, researchers gave them a self-completed questionnaire. Each child had 1 parent enroll in the study. The Strengthening the Reporting of Observational studies in Epidemiology (STROBE) guidelines were used to ensure the reporting of this observational study.²⁷ The study received medical approval from the Ethics Committee for Biomedical Research, University of Medicine and Pharmacy at Ho Chi Minh City (No 375/HDDD on 20 March 2023). Subjects participated in the study voluntarily; if the parents agreed to participate, they were asked to sign a consent form before taking the survey.

Inclusion and Exclusion Criteria

The inclusion criteria were parents with children studying at Nguyen Thi Minh Khai High School in Ha Tinh Province, Vietnam, from April to May 2023 who agreed to join the study. The exclusion criteria were parents with children vaccinated with the HPV vaccine (at least 1 dose).

Instrument

A structured questionnaire was designed based on previous studies of author Zhang KC et al,²⁸ author Marlow LA et al,²⁹ Theory of Planned Behavior (TPB),¹³ and The Health Belief Model (HBM).³⁰ The questionnaire comprises 5 parts, with 30 questions. The first part, with 7 questions, collected sociodemographic characteristics: age group ( $\leq$ 40, 41–50, >50 years), relationship with children, level of education, income, the parent’s opinion on the cost of the HPV vaccine, and sex of the child. In the second and third parts, 13 questions were used to determine parents’ knowledge regarding HPV diseases and HPV vaccine. In the fourth part, 9 questions assessed participants’ attitudes about letting their child take the HPV vaccine. For each correct answer, the participant will get 1 point. Parents were categorized as having sufficient knowledge and a positive attitude if they had more than 75% correct answers in each part.³¹ The final part of the questionnaire evaluated the parent’s intention to let their child get the HPV vaccine in the future. The participants were divided into 2 groups based on their answers, encompassing the have intention group and not have intention group.

The questionnaire was conducted in a pilot study on 30 participants before being used to provide clarity and understanding and address any biases. Parents in the pilot study were excluded from the main study.

Data Collection

Eligible participants were invited to complete the survey during school meetings. Investigators explained the study’s aims in detail before participants filled out the self-administered questionnaire, ensuring the accuracy and comprehensiveness of the collected data. Completing the survey took approximately 10-15 minutes.

Data Analysis

We used Epidata 3.1 and Stata 14.2 software for data entry and processing. The independent variable includes sociodemographic characteristics, knowledge about HPV disease, and attitude about HPV vaccination for the participant’s children. The dependent variable is the intention to vaccinate their child against HPV. The descriptive statistics with all variables were expressed as frequency and percentage. The univariate analysis employed the chi-square test. Next, significant variables (P-value <.05) were calculated using the multivariate logistic regression method, with odds ratio (OR) and 95% confidence interval (95% CI). Significance was considered when the P-value was less than .05.

Result

377 parents participated in the study (response rate was 93.5%). After screening according to the exclusion and inclusion criteria, 12 parents did not meet the requirements, and 365 parents were included in the data analysis.

The result illustrates that the proportion of mothers participating in the study was 3.3 times higher than that of fathers (76.7% and 23.3%). Many parents participating in the study were between the ages of 41-50 years (59%), had a high school education (37%), and had an income between 5-10 million VND (Vietnamese Dong)/month (53.4%). Most of the participants had ≥2 children (97.8%), with most parents having both boys and girls (67.9%). Finally, most parents thought the price of the HPV vaccine was not high (72.6%) with the cost of 1 dose of HPV vaccine ranging from 900,000 to 2,940,000 VND (Table 1).

Table 1.

Sociodemographic Characteristics of Participants (n = 365).

Sociodemographic Characteristics	n	%
Relationship with children
Father	85	23.3
Mother	280	76.7
The age group
$\leq$ 40	62	17.0
41-50	216	59.2
>50	87	23.8
Level of education
Below high school	107	29.3
High school	135	37.0
Above high school	123	33.7
Personal income per month
Under 5 million VN$	149	40.8
5 million to 10 million VN$	195	53.4
Over 10 million VN$	21	5.8
Number of children in the family
1	8	2.2
≥2	357	97.8
Sex of children
All boys	44	12.1
All girls	73	20.0
Both girls and boys	248	67.9
Think about the price of the HPV vaccin
High	100	27.4
Not high	265	72.6

Table 2 illustrates that approximately one-half of the participants had sufficient knowledge about HPV disease (47.7%). For instance, 51% of parents have heard about HPV before, and 45.7% believed that people who got HPV should be treated. 44.1% of the participants knew that the main transmission of HPV was through sexual intercourse, while 38.6% knew that a person could get HPV for many years without any symptoms. There were 46.3% of parents aware HPV has many genotypes, and 39.2% thought men could also get HPV. Only 9.6% of men and 17% of women knew of diseases caused by HPV (Table 2).

Table 2.

Knowledge About the HPV Disease and the HPV Vaccine (n = 365).

Knowledge	Sufficient
Knowledge	n	%
Heard of HPV before	186	51.0
There are many genotypes of HPV	168	46.3
People who have HPV may need to be treated	167	45.7
HPV is a sexually transmitted infection	161	44.1
Men can still contract HPV	143	39.2
A person could get HPV for many years without any symptoms	141	38.6
Diseases caused by HPV in women: Genital warts, cervical cancer, vaginal cancer	62	17.0
Diseases caused by HPV in men: genital warts, penile cancer, anal cancer	35	9.6
Knowledge about HPV disease	174	47.7
The HPV vaccine is now available	172	47.1
HPV vaccines are most effective if given to people who have never had sex	164	44.9
The HPV vaccine protects men	159	43.5
The best age to get the HPV vaccine is 9 - 26 years old	156	42.7
The HPV vaccination schedule is 2 - 3 doses based on age	139	38.1
Knowledge about the HPV vaccin e	162	44.4

The participants had a total score that indicates a sufficient knowledge in each knowledge section.

Furthermore, 47.1% of parents had sufficient knowledge about the HPV vaccine, and 44.9% indicated that the vaccine is the most effective method to prevent HPV-related diseases. 43.5% of participants knew HPV vaccination could still protect men; 42.7% indicated that the best age to get the HPV vaccine is 9 - 26 years old. The percentage of participants with sufficient knowledge regarding the HPV vaccine was 44.4% (Table 2).

Less than 10% of parents had a positive attitude toward vaccinating their child against HPV (9.6%). 78.3% of parents believed the HPV vaccine would be effective in controlling HPV-related disease, while 64.1% said vaccination could protect their children. However, 78.6% of participants thought the protection from an HPV vaccine lasts only a short time. More than half (60.3%) of the parents were willing to have their children vaccinated against HPV. 12.6% of participants had a positive attitude about the side effects of the HPV vaccine, and 58.1% thought their child was afraid of vaccination. 34.5% of parents said they had no time to vaccinate their children, and 33.2% believed that Vietnam would not have an adequate supply of HPV vaccine (Table 3).

Table 3.

Parents’ Attitude About Children’s HPV Vaccination According to the Theory of Planned Behavior (n = 365).

Attitude	Positive
Attitude	n	%
Taking up HPV vaccination can contribute to the control of HPV diseases	286	78.3
HPV vaccination is highly effective in protecting your children from HPV	234	64.1
Having my child receive HPV vaccination is easy for me if I want them to	220	60.3
My family members will support me in having my child take up HPV vaccination	178	48.8
My child is afraid of vaccination	153	41.9
I didn’t have time to vaccinate my children	126	34.5
Vietnam will have an adequate supply of HPV vaccine	121	33.2
The protection from an HPV vaccine lasts only a short time	78	21.4
My child could get severe side effects after HPV vaccination	46	12.6
Parents’ att itude	35	9.6

The participants had a total score that indicates a positive attitude in the attitudes section.

Over half of parents (55.9%) intend to have their children vaccinated against HPV, and 44.1% do not intend to.

In univariable analysis, the result showed a significant association between age, level of education, income per month, perspective about the price of the HPV vaccine, knowledge about HPV disease, HPV vaccine, and attitude of parents with their intention to vaccinate their children against HPV. No significant correlation was found between parents’ intention and their relationships with their children, the number of children in the family, or the gender of the children (Table 4).

Table 4.

The Association Between Characteristics With Parents’ Intention to Vaccinate Their Children Against HPV (n = 365).

Characteristics	Intention to Vaccinate Their Children Against HPV		P Value
Characteristics	Yes (n) (%)(n = 204) (55.9)	No (n) (%)(n = 161) (44.1)	P Value
Relationship with children
Father	48 (56.5)	37 (43.5)	.902
Mother	156 (55.7)	124 (44.3)	.902
Age of the parent (years
31-40	45 (72.6)	17 (27.4)	.011
41-50	115 (53.2)	101 (47.8)
>50	44 (50.6)	43 (49.4)
Level of education
Below high school	52 (48.6)	55 (51.4)	.012
High school	72 (53.3)	63 (46.7)
Above high school	80 (65.0)	43 (35.0)
Personal income per month
Under 5 million VN$	69 (46.3)	80 (53.7)	.001
5 million to 10 million	119 (61.0)	76 (39.0)
Over 10 million VN$	16 (76.2)	5 (23.8)
Number of children in the family
1	6 (75.0)	2 (25.0)	.207
≥2	198 (55.5)	159 (44.5)	.207
Sex of children
All boys	23 (52.3)	21 (47.7)	.665
All girls	44 (60.3)	29 (39.7)
Both girls and boys	137 (55.2)	111 (44.8)
Perspective on the price of the HPV vaccine
Expensive	79 (79.0)	21 (21.0)	<.001
Not expensive	125 (47.1)	140 (52.9)	<.001
Knowledge about HPV disease
Correct	88 (80.0)	22 (20.0)	<.001
Incorrect	116 (45.5)	139 (54.5)	<.001
Knowledge about the HPV vaccine
Correct	130 (80.3)	32 (19.7)	<.001
Incorrect	74 (36.5)	129 (63.5)	<.001
Parents’ attitude
Positive	33 (94.3)	2 (5.7)	<.001
not Positive	171 (51.8)	159 (48.2)	<.001

The P-value was calculated via the Chi-square test.

In multivariable analysis, the intention to vaccinate children was 3.3 times (odds ratio (OR) 3.3, 95% CI 1.2-6.2, P = .001) higher in parents with sufficient knowledge about the HPV disease, and 2.82 times (OR = 2.82, 95% CI 1.25-6.34, P = .012) higher with sufficient knowledge about HPV vaccine than those with insufficient knowledge. The intention to allow their child to be vaccinated was 11.4 times higher (OR = 11.4, 95% CI 2.45-53.9), P < .001) in participants with positive attitudes regarding vaccination against HPV than in those without positive attitudes (Table 5).

Table 5.

The Result of Multivariable Analysis of Associated Factors With Parents’ Intention to Vaccinate Their Children Against HPV.

Variables	Intention to Vaccinate Their Children Against HPV		OR (95% CI)	P
Variables	Yes (n) (%)(n = 204) (55.9)	No (n) (%)(n = 161) (44.1)	OR (95% CI)	P
Age of the parent (years)
31-40	45 (72.6)	17 (27.4)	1	.061
41-50	115 (53.2)	101 (47.8)	0.68 (0.46-1.01)
>50	44 (50.6)	43 (49.4)	0.46 (0.21-1.03)
Level of education
Below high school	52 (48.6)	55 (51.4)	1	.877
High school	72 (53.3)	63 (46.7)	0.97 (0.68-1.38)
Above high school	80 (65.0)	43 (35.0)	0.94 (0.46-1.90)
Personal income per month
Under 5m VND	69 (46.3)	80 (53.7)	1	.068
5 to 10m VND	119 (61.0)	76 (39.0)	1.54 (0.96-2.46)
Over 10m VND	16 (76.2)	5 (23.8)	2.37 (0.93-6.06)
Think about the price of the HPV vaccine
Expensive	79 (79.0)	21 (21.0)	1	.624
Not expensive	125 (47.1)	140 (52.9)	0.81 (0.36-1.83)	.624
Knowledge about HPV disease
Correct	88 (80.0)	22 (20.0)	3.34 (1.64-6.82)	.001
Incorrect	116 (45.5)	139 (54.5)	1	.001
Knowledge about the HPV vaccine
Correct	130 (80.3)	32 (19.7)	2.82 (1.25-6.34)	.012
Incorrect	74 (36.5)	129 (63.5)	1	.012
Parents’ attitude
Positive	33 (94.3)	2 (5.7)	11.4 (2.45-53.9)	<.001
Not positive	171 (51.8)	159 (48.2)	1	<.001

The P-value was calculated via the multivariate logistic regression.

Discussion

The current result indicates that 55.9% of parents intend to have their children vaccinated against HPV. This result is lower than the study in India (78.0%),²² Indonesia (96.1%),²¹ Japan (93%),³² Thailand (85%),¹⁷ but higher in some studies in China (26.5%),¹⁶ France (37.8%),²⁶ and Austria (32.4%).²⁴ It can be concluded that parents’ intention to vaccinate their children against HPV varies between countries. This may be due to the differences in parents’ characteristics in each country, such as knowledge about HPV, household income, religion, level of education, occupation, residence area, price of the HPV vaccine, and age of parents and children. These factors were indicated to have an effect on the intention of HPV vaccination of parents for their children in the previous studies.^{17,18,21,22,24} In addition, the disparity of health systems is an important reason. For instance, providing more information about HPV disease and HPV vaccines from health care workers, vaccine programs, getting the vaccine for free, or having the proper prices demonstrated could increase the acceptance and parents’ intention to vaccinate children.^{16-18,21,22,24,32}

Approximately one-third of participants have good knowledge about HPV diseases and HPV vaccines, with percentages of 30.1% and 44.4%, respectively. These findings are in line with previous studies that a lack of awareness about HPV is common.^15,18,19,33 This result may be due to: first, the effect of some characteristics. For instance, parents with higher income and levels of education will have greater HPV knowledge than those with lower levels.^16,18 Additionally, the HPV vaccine has not been added to the Expanded Program on Immunization in Vietnam for children. This leads to this vaccine being less popular and not given as much attention in the community as the other vaccines. In Austria, the HPV vaccine is free to all children 9-12 years old, and 85.4% of participants have knowledge about the vaccine.²⁴ Compared with China where the HPV vaccine is not licensed, just 10% person know about the vaccine.¹⁶ In this study, only 47.1% of parents knew the HPV vaccine was now available in Vietnam.

Parents with adequate knowledge about HPV diseases and the HPV vaccine have a higher percentage of HPV vaccination intentions for their children than parents who do not have knowledge by 3.34 times and 2.82 times, respectively. These results support the findings of previous studies.^16-20 In a study by the author L. Jaspers in Indonesia, the most common reason parents decided to let children be vaccinated with HPV is they believe HPV vaccination is effective. The second reason is that it is a good way to protect their child.²¹ Providing information about HPV might let parents recognize the high risk that this virus could have when infected. Moreover, they need to know that the HPV vaccine is the best way to protect their children, which may lead to the motivation to increase vaccine uptake rates.

Based on the analysis, individuals with a positive attitude were more inclined to vaccinate against HPV than those who did not have a positive attitude. This finding is consistent with the result of earlier research^17,21-23 that suggests a parent’s attitude towards HPV vaccination significantly determines their intention to vaccinate their children. Moreover, our research found many individuals cited concerns related to the HPV vaccine. Specifically, 87.4% of participants were worried about the vaccine’s potential side effects, 78.6% believed that the protection provided by the HPV vaccine was only temporary, and 58.1% thought their child was afraid of getting vaccinated. The reasons mentioned above aligned with earlier studies conducted by L. Jaspers and Madeleine W.^21,23 Some negative attitudes were identified and rarely mentioned in previous studies. For example, participants indicated they did not have time to get their children vaccinated, the children were afraid of vaccination, and they thought Vietnam still did not have an adequate supply of HPV vaccine. These negative attitudes about the HPV vaccine may decrease the percentage of parents who have the intention to vaccinate their children following the Theory of Planned Behavior.³⁴ Changing the parents’ attitude by providing the effect and safety of the HPV vaccine may help increase the intention to vaccinate their children.²²

Our study had some limitations. This is a cross-sectional study conducted at 1 point; each participant only collects information once and needs to be followed over time; hence, it is difficult to determine a cause-and-effect relationship. We provide more information to readers about the parents’ intention to vaccinate their children against HPV and identify the related factors, including knowledge and attitude, and how this may affect parents’ intention to vaccinate.

Conclusions

Many parents did not have the intention to vaccinate their children against HPV. Providing information about HPV diseases and vaccines to address the misconceptions that were identified may change the attitude regarding their intentions to vaccinate their children. The researchers hope that this study will increase the coverage of the HPV vaccination in children to prevent cancers caused by HPV.

Supplemental Material

Supplemental Material - Parents’ Intentions of Human Papillomavirus Vaccination for Students in Vietnam: A Cross-Sectional Study

Supplemental Material for Parents’ Intentions of Human Papillomavirus Vaccination for Students in Vietnam: A Cross-Sectional Study by Lam Thi Phuong Nguyen, Dung Quoc Phan, Araba Gyan, Han Thi Ngoc Nguyen, David Cassell, and Giao Huynh in American Journal of Health Promotion

Footnotes

Acknowledgments

We wish to acknowledge the support of the teachers at the high school in Ha Tinh province who facilitated the study. We thank all the participants for the time and effort that they devoted to the study.

Author Contributions

All authors contributed substantially to drafting, revising, and approving the article’s final version. Lam Thi Phuong Nguyen and Giao Huynh contributed to the conception and design of the study and acquisition of the data. Dung Quoc Phan and Lam Thi Phuong Nguyen cleared and analyzed the data. Dung Phan Quoc, Araba Gyan, Han Thi Ngoc Nguyen, David Cassell, and Giao Huynh were the contributors to the interpretation of the data.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical Statement

ORCID iD

Giao Huynh

Data Availability Statement

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

Supplemental Material

Supplemental material for this article is available online.

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