Co-authored by Anuska Roy and Shubham Grover
Cervical cancer is a significant contributor to cancer-related mortality among women globally, with over a quarter of its burden borne by developing nations like India. Despite being the most preventable form of cancer, one woman dies of cervical cancer every eight minutes in India.
In 2020, cervical cancer accounted for 9.4% of new cancer diagnoses and claimed the lives of nearly 70,000 women in India.1 Human papillomavirus (HPV), a prevalent sexually transmitted infection (STI), was responsible for almost 95% of these cases.2 These statistics underscore the necessity of implementing an immunization program aimed at vaccinating women against the HPV virus.
WHO has estimated that vaccination against nine strains of HPV has the potential to reduce the incidence of cervical cancer by half across all age groups by 2061. Moreover, with the addition of twice-lifetime screening, this milestone could be achieved even sooner, possibly by 2048.3 However, for India, which accounts for a quarter of all global deaths attributed to cervical cancer4, this battle seems like an uphill task owing mainly to inadequate screening and limited access to HPV vaccination.
Youth Ki Awaaz and Nivi partnered to check awareness levels among young people about HPV, its vaccine, cervical cancer. Youth Ki Awaaz formulated a quiz to check awareness levels among young people, especially young women about cervical cancer and the HPV vaccine as well as to provide them with much needed information about it. Nivi deployed its digital platform askNivi to survey young people about their health-seeking behavior pertaining to HPV & cervical cancer and to connect them to a health facility for further guidance and screening. More than 5000 people interacted with the askNivi HPV and Cervical Cancer health journey and responded to questions around perceived importance of vaccination and screenings, their readiness to act and visit a health facility, their willingness to pay for the preventative services as well as the barriers that kept them from acting for better health.
Insights from the YKA Quiz
The highest percentage (22%) of quiz takers scored 7 out of 11. Studies highlight a significant lack of awareness about cervical cancer in India. In a recent study, women have highlighted low knowledge about the vaccine and concerns about potential complications as significant barriers to vaccination.5 The quiz highlighted that 48% were aware that stigma is the most significant barrier for women to get vaccinated against HPV. This underscores the urgent need for comprehensive awareness programs to be implemented in rural and urban areas.
This issue about concerns around vaccination is particularly pronounced in younger age groups, where misconceptions about the “right” age for vaccination can hinder uptake. 38.5% of quiz takers think the vaccine can only be administered to girls between 9 and 14. While the vaccine is most effective in young, sexually inactive women, it still provides valuable protection for sexually active women of reproductive age, a fact that many remain unaware of.
39.4% of quiz takers were also aware that a tiny percentage of women in India get screened for cervical cancer. NFHS-5 revealed that only 2% of Indian women were ever screened for cervical cancer. While in high-income countries, this number is as high as 63%. A study also showed that women from general castes, Muslim communities and affluent groups are less likely to get themselves screened due to the stigma associated with sexual activities, a significant cause of cervical cancer.6
Reducing the prevalence of diseases hinges on providing comprehensive health education and instituting efficient early screening measures. In countries like India, where resources are limited, affordable screening and treatment options are essential. This underscores the urgency for authorities to enact targeted policies encompassing a robust healthcare framework alongside cost-effective screening and treatment solutions.
Encouragingly, several South Asian countries have initiated national HPV vaccination programs for girls, demonstrating proactive measures in combating cervical cancer. Bhutan led the charge as early as 2010, followed by Thailand and Sri Lanka in 2017 and the Maldives in 2019, while Bangladesh undertook pilot projects to assess feasibility. 48.2% of quiz takers knew that India does not have a national HPV vaccination program. To eliminate cervical cancer, WHO has set a goal of vaccinating 90% of girls in the 9-14 age group by 2030. On February 1, Union Finance Minister Nirmala Sitharaman unveiled the government’s prioritization of vaccination against cervical cancer during her Interim Budget 2024 address. 7
National immunization programs are pivotal in safeguarding public health by combating prevalent diseases. The uptake of vaccinations for cervical cancer has been sluggish, primarily due to the financial burden they impose, with each dose costing approximately Rs 4,000 and requiring two to three doses. Dr. Shuchin Bajaj, founder and director of the Ujala Cygnus Group of Hospitals, highlights a promising solution: integrating the HPV vaccine into the country’s immunization regimen.8
While the inclusion of the HPV vaccine in National Immunization Programs could significantly reduce the financial barriers hindering widespread access to cervical cancer prevention. By making these vaccines more accessible and affordable, the various health system stakeholders can effectively combat the prevalence of cervical cancer and ensure the well-being of women and men across the nation.
Health-seeking behavior insights from askNivi HPV survey
When Nivi surveyed askNivi users on their perceived importance to vaccinate girl and boy child, majority of the individuals (74%) between the ages 15-26 said they felt it was important to vaccinate against HPV, with women exhibiting higher perceived importance to vaccine than men. Individuals from Urban areas felt it was more important than those from Rural areas indicating the need to implement awareness programs across both demographic settings.
While people generally believe it’s important to vaccinate against HPV, they aren’t ready to act immediately. Only 57% of the respondents between the ages 15-26 said they felt ‘very ready’ to act immediately and visit a health facility to get the HPV. While there was no significant different observed in readiness between individuals coming from Urban or Rural areas, askNivi saw that Women were generally more ready to act as compared to men, which also relates to the higher perceived importance observed in this cohort.
It’s evident that there are barriers that are at play and that keep people from acting for better health. 25% of the users that said they were ‘not ready’ said that they felt the time was not appropriate for them to get vaccinated whereas 23% said that they needed more information before they act and visit a doctor, while 14% of those said they were concerned about side effects of the vaccine.
These collectively highlight the urgent need to launch targeted education campaigns that address concerns around the urgency to act on this critical issue as well as offer personalized advice to drive behavior change leading to uptake of preventive services. Another area that the healthcare stakeholders need to work on is the accessibility of the HPV vaccine. A significant 13% of users said they didn’t have the financial resources to get the HPV vaccine. This barrier was more pronounced in women aged 15-26 than men where 21% of women said they lack the financial resources compared to only 8% of men who felt unready to act.
A significant 16% of the male respondents said that they didn’t believe the HPV vaccine was for them and 10% said they weren’t worried about HPV. It’s important to acknowledge that both men and women can acquire and transmit the virus. Up to 25% of men harbor at least one high-risk HPV subtype. It is, hence, essential that cervical cancer prevention hinges significantly on the vaccination of both genders. Vaccinating boys can help reduce the overall burden of HPV-related diseases. The long-term effects of vaccinating only one gender could lead to a perpetuation of gender disparities in healthcare access and outcomes. Experts assert that including boys in vaccination programs is paramount to reducing cases of cervical cancer, particularly in countries like India. They advocate for the implementation of gender-neutral vaccination programs, emphasizing the importance of comprehensive strategies in combating the prevalence of HPV-related diseases and safeguarding public health.
The battle against cervical cancer looms large on the global health agenda, especially in developing nations like India, where it takes a heavy toll on women’s lives. The significance of national immunization programs cannot be overstated to shield especially vulnerable communities from diseases. Vaccines have historically been instrumental in curbing the spread of once-deadly illnesses. Efforts to combat this disease must encompass robust education campaigns alongside efficient screening measures, ensuring that all women, regardless of background, have access to life-saving interventions.
Efficient screening measures are equally vital in early detection and treatment of cervical cancer. Regular screenings can detect precancerous lesions or early-stage cancer, allowing for timely intervention and significantly improving treatment outcomes. Implementing cost-effective screening programs, such as VIA (visual inspection with acetic acid) or HPV testing, can help ensure that screenings are accessible to all women, regardless of socioeconomic status. While it’s wonderful to see health systems responding to the urgency of cervical cancer prevention, a similar focus on generating awareness and deepening the resolve to act (get vaccinated/screened) is equally important. It’s essential to recognize that additional behavior change interventions may be necessary to ensure comprehensive protection against HPV-related diseases.
Governments and health system actors like promoters, providers, and payors, should also consider national catchup vaccinations for individuals between the ages of 15 to 26 years who won’t come under the National Immunization Program. The importance of vaccinating young boys and girls under the age of 26 years extends far beyond individual health outcomes; it encompasses broader public health and societal benefits. Moreover, these efforts also contribute to reducing long-term healthcare costs associated with treating vaccine-preventable diseases. Prevention is often more cost-effective than treatment, as the costs of vaccinations are significantly lower than the costs of hospitalization, medication, and long-term care for individuals suffering from vaccine-preventable diseases. By investing in immunization, healthcare stakeholders can alleviate the economic burden on healthcare systems and improve healthcare affordability and accessibility for all citizens.
Editor’s Note: This article is part of a collaborative effort between Youth Ki Awaaz and Nivi aimed at raising awareness about the HPV vaccine and cervical cancer.
References:
- Cervical Cancer: Formulation and Implementation of Govt of India Guidelines for Screening and Management ↩︎
- “Cervical Cancer.” World Health Organization, www.who.int/news-room/fact-sheets/detail/cervical-cancer#:~:text=Persistent%20HPV%20infection%20of%20the,causes%2095%25%20of%20cervical%20cancers. Accessed 03 May 2024. ↩︎
- “HPV Vaccination and the Quest to Solve India’s Cervical Cancer Problem: Think Global Health.” Council on Foreign Relations, 24 Oct. 2022, www.thinkglobalhealth.org/article/hpv-vaccination-and-quest-solve-indias-cervical-cancer-problem#:~:text=A%20study%20published%20in%20The,cervical%20cancer%20in%20all%20age. Accessed 03 May 2024. ↩︎
- Singh, Deependra, et al. “Global Estimates of Incidence and Mortality of Cervical Cancer in 2020: A Baseline Analysis of the WHO Global Cervical Cancer Elimination Initiative.” The Lancet Global Health, vol. 11, no. 2, 14 Dec. 2022, doi:10.1016/s2214-109x(22)00501-0. ↩︎
- Yadav, Ritu, et al. “Awareness Data on Cervical Cancer among Females of Rural and Urban Areas of Haryana, India.” Data in Brief, vol. 53, Apr. 2024, p. 110168, doi:10.1016/j.dib.2024.110168. ↩︎
- Afsah, Yusi Riwayatul, and Noriyo Kaneko. “Barriers to Cervical Cancer Screening Faced by Immigrant Muslim Women: A Systematic Scoping Review.” BMC Public Health, vol. 23, no. 1, 30 Nov. 2023, doi:10.1186/s12889-023-17309-9. ↩︎
- Bureau, The Hindu. “Budget 2024: Government to Focus on Vaccination against Cervical Cancer.” The Hindu, 2 Feb. 2024, www.thehindu.com/business/budget/govt-to-focus-on-vaccination-against-cervical-cancer-announces-finance-minister-nirmala-sitharaman/article67799549.ece. Accessed 03 May 2024. ↩︎
- “Govt Push Puts Spotlight on Cervical Cancer, Experts Hope It Is Possible Turning Point.” The Indian Express, 9 Feb. 2024, indianexpress.com/article/india/cervical-cancer-vaccine-experts-9153010/. Accessed 03 May 2024. ↩︎