Cervical cancer is the fourth most common cancer among women worldwide, with an estimated 662,301 new cases and 348,874 deaths in 2022.^1,2 Persistent infection with high-risk human papillomavirus (HPV) types, particularly HPV 16 and 18, is the principal aetiological factor and accounts for more than 70% of cases globally.^3,5 India bears nearly one-fifth of the global burden: cervical cancer is the second most common cancer among Indian women and a leading cause of cancer-related death, with 127,526 new cases and 79,906 deaths in 2022.^2,4,6 The World Health Organization (WHO) global strategy for elimination sets the 90-70-90 targets, including full HPV vaccination of 90% of girls by 15 years of age by 2030, and 17 November has been observed as World Cervical Cancer Elimination Day since 2020.^1,7

Cervical cancer is largely vaccine-preventable. The WHO recommends vaccinating girls aged 9–14 years, preferably before sexual debut, which is highly effective in preventing HPV infection and subsequent HPV-related disease.⁸ Several Indian states have introduced school-based or public HPV immunisation programmes,⁹ and on 28 February 2026 the Government of India launched a nationwide campaign offering free HPV vaccine to girls aged 14 years, an important milestone in cervical cancer prevention.¹⁰

Despite these efforts, HPV vaccine uptake in India has remained suboptimal because of limited public awareness, sociocultural misconceptions, financial constraints and concerns regarding vaccine safety and efficacy.¹¹ The high cost of imported vaccine has repeatedly been cited as a reason for low acceptance,¹² and other reported barriers include parental or community hesitancy, perceived social stigma and limited health education.¹³ The Health Belief Model (HBM) offers a useful framework for understanding how these factors shape vaccine acceptability (Figure 1).^14,15

Figure 1. Conceptual framework based on the Health Belief Model, applied to HPV vaccine acceptability among school-going girls aged 14 years. Modifying factors act through perceived beliefs and cues to action to influence acceptability and uptake.

Evidence on acceptability among girls of exactly the age targeted by the national programme, and on differences between urban and rural adolescents, remains limited. This study therefore aimed to compare the knowledge, awareness, acceptability and uptake of HPV vaccination among urban and rural girls aged 14 years. The specific objectives were (i) to assess knowledge of HPV infection and its association with cervical cancer, (ii) to assess awareness and acceptability of HPV vaccination and (iii) to compare these outcomes between urban and rural girls in relation to their sociodemographic characteristics.

Study design and setting A school-based comparative cross-sectional study was conducted from October 2025 to June 2026 in government schools of Dadra and Nagar Haveli district, Union Territory of Dadra and Nagar Haveli and Daman and Diu, India. The study is reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement. Participants The study population comprised school-going girls aged 14 years (i.e. who had not completed 15 years of age) enrolled in the selected government schools. Girls were eligible if they were enrolled in a selected school, if a parent or guardian provided written informed consent and if they provided written assent. Students who were unwilling to participate, were absent on the day of data collection or returned incomplete or incorrectly completed questionnaires were excluded. Sample size and sampling A total of 400 girls were included, with equal representation from urban (n=200) and rural (n=200) schools. With 200 participants per group, the study had 80% power at a two-sided α of 0.05 to detect an absolute urban–rural difference of approximately 14 percentage points for proportions in the range of 30–45%. A multistage random sampling technique was used. In the first stage, all government schools in the district were stratified into urban and rural strata according to their geographical location. In the second stage, schools were selected from each stratum by simple random sampling. In the third stage, eligible girls in the selected schools were listed and selected by simple random sampling until the required sample size was achieved. Data collection tool and variables Data were collected using a structured, pre-tested, self-administered questionnaire developed after a review of the literature and consultation with subject experts, who also assessed its content validity. The questionnaire was pre-tested among girls who were not included in the final sample. It comprised five sections: (i) sociodemographic characteristics, including religion, parental education, type of family and socioeconomic status (classified using Modified Kuppuswamy/B.G. Prasad]; (ii) knowledge of cervical cancer and HPV infection; (iii) awareness of HPV vaccination; (iv) attitudes towards and acceptability of HPV vaccination; and (v) vaccination practices and intention to receive the vaccine in future. The primary outcomes were willingness to be vaccinated and self-reported receipt of HPV vaccine. The questionnaire was administered through Google Forms in the classroom under the supervision of the investigators, after permission had been obtained from school authorities. Investigators clarified procedures but did not prompt responses, and no personal identifiers were recorded, to minimise social desirability bias and maintain confidentiality. Statistical analysis Data were entered into Microsoft Excel and analysed as frequencies and percentages. Overall proportions for key outcomes are presented with Wilson 95% confidence intervals (CIs). Differences between urban and rural participants were assessed using Pearson's chi-square test; Fisher's exact test (Monte Carlo estimate for tables larger than 2×2) was used when more than 20% of cells had an expected frequency below five. For binary outcomes, odds ratios (ORs) with 95% CIs (Woolf method) were calculated with rural participants as the reference group. Analyses were performed using Python 3 (SciPy and statsmodels libraries). All tests were two-sided, and p<0.05 was considered statistically significant. Only complete questionnaires were analysed. Ethical considerations The study was approved by the Institutional Scientific Review and Ethics Committee of NAMO Medical Education and Research Institute, Silvassa (Letter No. NAMOMERI-SVBCH/IEC/2023-24/231, dated 04/04/2026) before data collection. Prior permission was obtained from the Dean and the Medical Superintendent of the institute and from the respective school authorities. Written informed consent was obtained from parents or guardians, and written assent was obtained from all participating girls. Participation was voluntary and responses were anonymous.

A total of 400 girls aged 14 years participated, 200 from urban and 200 from rural government schools, and all were included in the analysis.

Sociodemographic characteristics

Sociodemographic characteristics are shown in Table 1. Most participants were Hindu in both urban (74.0%) and rural (79.0%) areas, and religious distribution did not differ significantly (p=0.054). Parental educational attainment was markedly lower among rural participants: 15.5% of rural and 6.0% of urban fathers, and 41.0% of rural and 14.5% of urban mothers, were illiterate (both p<0.001). More than half of rural participants (55.0%) belonged to the lower socioeconomic class, compared with 12.0% of urban participants (p<0.001). Extended families were more common in rural areas.

Table 1. Sociodemographic profile of participants, by place of residence (n=400)

Values are n (%). p-values from Pearson's chi-square test. Rural type-of-family counts sum to 240 (120%) in the source data and must be corrected before submission.

Awareness and knowledge of HPV

Awareness of cervical cancer was substantially higher among urban than rural girls (85.0% vs 55.0%; OR 4.64, 95% CI 2.88–7.48; p<0.001) (Table 2). In contrast, only 179 girls (44.75%; 95% CI 39.95–49.65) had heard of HPV, with no urban–rural difference (p=0.92). Fewer than one-third (122; 30.5%) knew that HPV causes cervical cancer (p=0.36), and 386 (96.5%) did not know how HPV is transmitted. Urban girls were more likely to know that multiple sexual partners increase risk (45.0% vs 10.0%; OR 7.36, 95% CI 4.29–12.63; p<0.001) and that vaccination is most effective before the onset of sexual activity (35.0% vs 8.0%; OR 6.19, 95% CI 3.44–11.15; p<0.001). Only 20 girls (5.0%) had registered for HPV vaccination (p=0.17).

Table 2. Awareness and knowledge of cervical cancer, HPV and HPV vaccination, by place of residence (n=400)

Values are n (%). p-values from Pearson's chi-square test; †Fisher's exact test (Monte Carlo). HPV, human papillomavirus.

Sources of information

Schools and teachers were the most common source of information (137; 34.25%), whereas health professionals (6; 1.5%), mass media (6; 1.5%) and family or friends (7; 1.75%) were rarely cited (Table 3). More than half of the girls (221; 55.25%) had never received any information on HPV or HPV vaccination. The distribution of information sources differed between urban and rural participants (p=0.014).

Table 3. Sources of information on HPV and HPV vaccination, by place of residence (n=400)

Values are n (%). †Fisher's exact test (Monte Carlo), as more than 20% of cells had expected frequencies below five. HPV, human papillomavirus.

Vaccine-specific knowledge

Overall, 277 girls (69.25%; 95% CI 64.56–73.57) reported having heard of the HPV vaccine, with no significant urban–rural difference (p=0.33) (Table 4). Knowledge of eligible recipients differed by residence (p=0.020): 212 (53.0%) identified girls as vaccine recipients, 39 (9.75%) knew that both sexes can be vaccinated and 149 (37.25%) did not know. Although 236 (59.0%) identified an age below 14 years as the recommended age for vaccination, 297 (74.25%) did not know the dosing schedule, and only 99 (24.75%) recognised that the vaccine prevents HPV infection, whereas 46 (11.5%) believed that it treats the infection.

Table 4. HPV vaccine-specific knowledge, by place of residence (n=400)

Values are n (%). p-values from Pearson's chi-square test; †Fisher's exact test (Monte Carlo). HPV, human papillomavirus.

Attitudes, acceptability and uptake

Overall, 242 girls (60.5%) considered HPV vaccination important, more often in urban than rural areas (65.5% vs 55.5%; OR 1.52, 95% CI 1.02–2.28; p=0.041) (Table 5). Willingness to be vaccinated was low (94; 23.5%; 95% CI 19.61–27.90) and was higher among urban girls (30.5% vs 16.5%; OR 2.22, 95% CI 1.37–3.59), while outright refusal was more frequent among rural girls (73.5% vs 52.0%; p<0.001). Only 11 girls (2.75%; 95% CI 1.54–4.86) had received the HPV vaccine, with no urban–rural difference (3.5% vs 2.0%; p=0.36). Intention to be vaccinated in future was expressed by 110 girls (27.5%), and a further 88 (22.0%) were undecided; future intention was higher among urban girls (35.5% vs 19.5%; OR 2.27, 95% CI 1.44–3.58; p<0.001).

Table 5. Attitudes, acceptability and uptake of HPV vaccination, by place of residence (n=400)

Values are n (%). p-values from Pearson's chi-square test. HPV, human papillomavirus.

In this comparative study of girls of the age targeted by India's national HPV vaccination programme, fewer than half had heard of HPV, fewer than one-third knew that it causes cervical cancer, and fewer than three in 100 had been vaccinated. Urban girls had substantially greater awareness of cervical cancer and its risk factors and were about twice as likely as rural girls to be willing to be vaccinated or to intend future vaccination, although awareness of HPV itself was uniformly low. The urban–rural differences in parental education and socioeconomic status observed here mirror those reported by Veena et al., who found that 42% of urban and 19% of rural adolescents had parents educated to graduate level or higher and that urban girls more often belonged to middle and upper socioeconomic strata.16 Our findings are consistent with Indian studies showing that higher parental education and socioeconomic status are associated with greater awareness of HPV and cervical cancer. Gupta et al. reported significantly lower awareness among women from lower socioeconomic backgrounds,17 and Kumari et al. identified limited educational attainment as a key determinant of poor HPV awareness in rural populations.18 Together, these data underline the influence of educational and socioeconomic disparities on adolescent health literacy. Knowledge that HPV causes cervical cancer was poor in both groups (30.0% urban, 31.0% rural). Veena et al. reported good knowledge of HPV and its vaccine among 48% of urban but only 7% of rural girls, and awareness of cervical cancer among 84% and 45%, respectively, figures closely comparable with our 85.0% and 55.0%.16 Kumari et al. found that 94% of rural adolescents in eastern Uttar Pradesh had never heard of HPV,18 and Gupta et al. reported that fewer than half of adult women were aware of the HPV vaccine.17 By contrast, more than 90% of nursing officers and doctors surveyed by Mandal et al. recognised HPV as the cause of cervical cancer,13 illustrating the gap between health professionals and the general population. Low knowledge is not confined to India: in Oman, 40.5% of women did not know of any association between cervical cancer and infection.19 Knowledge of risk factors was also limited, particularly among rural girls, only 10.0% of whom knew that multiple sexual partners increase risk. Al-Azri et al. similarly found low overall awareness of cervical cancer risk factors (28.5%) among Omani women,21 and Al Raisi et al. recommended incorporating information on cervical cancer and HPV into school curricula and improving access to trusted medical information through social media to correct misinformation.20 The predominance of schools and teachers as information sources in the present study, together with the minimal contribution of health professionals, supports this recommendation. Willingness to be vaccinated was low overall (23.5%) and lowest among rural girls (16.5%), 73.5% of whom were unwilling. Veena et al. likewise reported low willingness, with no rural and only 6% of urban respondents willing to be vaccinated.16 Concerns regarding vaccine safety, lack of awareness and perceived lack of necessity have been identified as major contributors to hesitancy,17,18 whereas approximately 70% of health professionals in the study by Mandal et al. held positive attitudes towards vaccination, suggesting that better knowledge is associated with greater acceptance.13 Fear of side effects, cost and doubts about efficacy are the barriers most frequently reported in Indian studies,12,13,17 and Gupta et al. observed that willingness increased substantially when the vaccine was offered free of charge.17 Because vaccine is now provided free under the national campaign, cost should no longer be a barrier for this age group; the low willingness observed here therefore points to informational and attitudinal barriers that require targeted risk communication, particularly in rural communities. Uptake was very low (2.75%) in both settings. Because data collection (October 2025 to June 2026) spanned the launch of the national campaign on 28 February 2026, these estimates partly reflect the period before free vaccine became available and should be interpreted as a baseline against which programme progress can be measured. Strengths and limitations The strengths of this study include its focus on girls of exactly the age targeted by the national programme, random selection of schools and participants within urban and rural strata, equal group sizes permitting direct comparison, and use of a standardised self-administered questionnaire. The study also has limitations. First, its cross-sectional design precludes causal inference. Second, data were self-reported and may be subject to recall and social desirability bias, particularly for sensitive items, although self-administration and anonymity were intended to reduce this. Third, only government schools in a single district were included, which limits generalisability to private-school students and other regions. Fourth, the analysis was bivariate; urban–rural differences may be partly confounded by parental education and socioeconomic status, which were not adjusted for in multivariable models. Fifth, willingness rather than longitudinally measured uptake was assessed, and parental knowledge and attitudes and health-care provider recommendation, which are important determinants of adolescent vaccination, were not examined.

There is a considerable gap between the HPV vaccination status of 14-year-old school-going girls and the WHO target of 90% of girls fully vaccinated by 15 years of age by 2030; only 2.75% of girls in this study had been vaccinated. Knowledge of HPV was poor irrespective of residence, and acceptability was markedly lower among rural girls. Strengthening school-based vaccination services, age-appropriate health education, parental engagement and communication by health-care providers, with focused support for underserved rural communities, is needed. Future studies should assess parental determinants and use multivariable and longitudinal designs to evaluate uptake after the national campaign.

Declarations

Acknowledgements: The authors thank the school authorities, teachers and all the girls who participated in this study for their time and cooperation, and the faculty members and students who assisted with data collection.

Ethics approval and consent to participate: Approved by the Institutional Scientific Review and Ethics Committee, NAMO Medical Education and Research Institute, Silvassa (Letter No. NAMOMERI-SVBCH/IEC/2023-24/231, dated 04/04/2026). Written informed consent was obtained from parents or guardians and written assent from all participants.

Conflicts of interest: The authors declare no conflicts of interest.

Funding: This study received no external funding.

Data availability: The data supporting the findings of this study are available from the corresponding author on reasonable request.

Use of artificial intelligence: AI-assisted tools were used for language editing, preparation of the conceptual framework figure and independent re-computation of p-values and confidence intervals from the aggregated data. The authors reviewed and verified all AI-assisted content and take full responsibility for the accuracy, originality and integrity of the manuscript. AI was not used for data collection or generation of study data.

Author contributions: All authors (Mitali Patel, Darshan K. Mahyavanshi, Ayush Upadhyay, Ayush Sachan and Aryan Bamaniya) contributed to the concept and design, literature search, data acquisition, data and statistical analysis, and preparation, editing and review of the manuscript. Mitali Patel is the guarantor.

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