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Original article

Determinants of the human papillomavirus (hpv) vaccination intention among students

Marijana Milošević Gačević1, Sandra Petrović1
  • Secondary Medical School Dr Andra Jovanović, Šabac, Serbia

ABSTRACT

Introduction: Human papillomavirus (HPV) is the virus that is most often associated with cancers. Cervical cancer is one of the leading public health problems, especially in developing countries. In the Republic of Serbia, cervical cancer is the fifth most common cancer in the female population amongst all malignant diseases, and HPV infection is the most important risk factor for the occurrence of this disease. This study aims to identify the determinants of adolescent HPV vaccination intention.

Materials and methods: The study was conducted as a cross-sectional study including a total of 748 students, aged 12 –19 years, from one high school and two elementary schools in Šabac. The research instrument was a questionnaire, particularly constructed for this study. Multiple regression analysis was applied to examine the predictive model for explaining the HPV vaccination intention in young people.

Results: The proposed model explains 66% of HPV vaccination intention in young people. The strongest predictor of HPV vaccination intention in young people relates to the subjective norm, i.e., social pressure from peers and other people who are important to them. Distrust of the benefit of vaccination, concern about commercial profiteering, and belief in a “vaccine conspiracy” have a significantly smaller but statistically significant contribution in explaining HPV vaccination intention amongst our youth.

Conclusion: Increasing social pressure to get vaccinated, as well as changing certain attitudes and beliefs about vaccines in general, may lead to an increase in the intention of young people to get vaccinated against HPV. Understanding the key aspects of the attitudes of young people in Serbia towards HPV vaccination opens the possibility of creating evidence-based public health policies and planning targeted health-educational interventions directed at the identified findings.


INTRODUCTION

Human papillomavirus (HPV) is one of the most common viruses associated with cancers (as many as 690,000 new cases in 2018) [1]. There are more than 200 types of HPV, and they are divided into low and high oncogenic risk types [2],[3]. The most important types of HPV with low oncogenic risk are 6, 11, 42, 43, and 44, while the most important types of HPV with high oncogenic risk are 16, 18, 31, 33, 34, 35, 39, 45, 51, 52, 56, 58, 59, 66, 68, and 70 [4]. The majority of infections caused by HPV can clear spontaneously, without any consequences, while a certain number of infections will cause cancer of the cervix, vulva, vagina, anus, penis, oropharynx, etc.

Cervical cancer is one of the leading public health problems, especially in developing countries [5],[6]. Globally, cervical cancer ranks fourth among cancers in women, while among women aged 15 – 44 years, it ranks second [7]. In the Republic of Serbia, cervical cancer ranks fifth in frequency, and its potential cause, in most cases, is the HPV virus (the most oncogenic are types 16 and 18, which cause over 70% of cases). As to the population aged 15 – 44 years, cervical cancer ranks second [8]. It is important to emphasize that, according to the available data, cervical cancer accounts for 6% of deaths among women in Serbia. This statistic reflects the importance of preventing infection with this type of virus [9].

The HPV vaccine stands out as the most modern form of primary prevention of this type of viral infection. This type of vaccine prevents the development of an infection caused by those strains of the virus from which the vaccine itself is made [10]. The quadrivalent vaccine (against strains 6, 11, 16, and 18) was approved by the U.S. Food and Drug Administration (FDA) in 2006, while the bivalent vaccine (against strains 16 and 18) was approved in 2009. Both are administered between ages 9 and 26, depending on the country. In 2006, the United States of America (USA) introduced these vaccines into the national immunization program [11] and the effectiveness and reduction of prevalence for types 6, 11, 16, and 18 was proven in 89% of vaccinated cases in sexually active women aged 14 – 24 years [12]. By the year 2020, the HPV vaccine had been introduced into immunization programs in 55% (107) of countries worldwide [13].

Vaccination with the HPV vaccine is recommended for adolescents aged 11 or 12, but it can be started as early as 9 years old. If it has not been done before, vaccination can be carried out until the age of 26. After the age of 26, this type of vaccine is not recommended, because in most cases the person has already been exposed to the HPV virus, and the vaccine will not be effective enough. The vaccination itself is administered in two or three doses, which depends on the age and vaccination status of the person being vaccinated [14]. Numerous studies have proven that both types of HPV vaccines stimulate an appropriate immune response in both women and men [15],[16].

In April 2022, the Strategic Advisory Group of Experts on Immunization of the World Health Organization expressed great concern about the low number of fully immunized persons (the 2020 estimated global coverage of the second dose in girls was 13%). Low immunization coverage, a very small number of newly vaccinated persons, a high rate of discontinuation of immunization after receiving one dose of the vaccine, as well as the harmful impact of the COVID-19 pandemic were registered [17].

In the Republic of Serbia, the following three vaccines against HPV have been registered: Cervarix®, Gardasil®, and Gardasil®9 [18], but they have not been introduced into the mandatory immunization schedule [19], and the rate of vaccination is very low. One of the studies dealing with the problem of HPV vaccine immunization in the Republic of Serbia was conducted in Southeast Serbia. A total of 615 subjects participated in the research, of which 499 subjects received the first dose, and 116 the second dose. In the age groups 9 – 14 years and 15 – 19 years, 3.1 times more girls than boys were vaccinated. Given that parents are an extremely important link in the approval of immunization, this type of vaccine was used to examine the socio-demographic characteristics of parents, where it was determined that in 90.2% of cases, the parents were from urban (city) areas, while the rest were from rural areas. It was also determined that in 59.9% of cases, the parents had medical training [20].

Based on the report on immunization carried out in the territory of the Republic of Serbia, submitted by the Institute of Public Health of Serbia Dr Milan Jovanović Batut, as of December 31, 2022, a total of 20,130 doses of Gardasil®9 vaccine was administered. In the period June – December 2022, 20,130 doses of the planned 41,152 doses of the Gardasil 9 vaccine were administered throughout the territory of the Republic of Serbia [21]. As it was established that a small part of the target population was immunized, the national campaign “Together against cervical cancer - HPV NO” was launched in 2023 [22].

In the European Union, numerous studies were conducted with the aim of determining the level of knowledge that the parents and adolescents have about HPV and the HPV vaccine, all with the aim of improving the percentage of vaccinated adolescents [23-26], while in the Republic of Serbia, a study was conducted on knowledge, parental attitudes, and practices regarding HPV vaccination [27].

This study aims to define the determinants of adolescent HPV vaccination intention.

MATERIALS AND METHODS

Study type and selection of respondents

This cross-sectional study was conducted in one secondary and two elementary schools in Šabac, Serbia, in December 2022. The sample included 748 young people from Serbia, aged 12 to 19 years. Students of senior grades of the two elementary schools and students of years one to four in the secondary medical school participated in the study. Questionnaires were distributed in a group setting during class, using a paper and pencil format. All participants signed an informed consent form and received no compensation for their participation in the study.

Research instruments

A questionnaire consisting of several segments was used as a research instrument. The first segment included questions about the respondents’ sociodemographic data (gender, age, place of residence, etc.). In the remaining segments of the questionnaire, validated scales were used: the Vaccination Attitudes Examination Scale (VAX) [28], the Vaccine Conspiracy Beliefs Scale (VCBS) [29], the Vaccination Knowledge Scale (VKS) [30], as well as specially constructed segments of the questionnaire containing questions about respondents’ intentions regarding HPV vaccination, subjective norms, and perceived behavioral control.

The Vaccination Attitudes Examination Scale (VAX) is a 12-item questionnaire that assesses overall attitudes about vaccines. The VAX has four subscales, each with three items: mistrust of vaccination benefits (e.g., “I feel safer after vaccination”), concerns regarding unforeseen future effects (e.g., “Vaccines can cause unexpected problems in children”), concerns regarding commercial profiteering (e.g., “Vaccines make a lot of money for pharmaceutical companies but little for ordinary people”), and favoring natural immunity (e.g., “Natural immunity lasts longer than vaccination”). Each item is rated on a 6-point scale, where 1 indicates: “Strongly disagree” and 6 indicates: “Strongly agree” [28].

The Vaccine Conspiracy Beliefs Scale (VCBS) consists of seven items that measure the belief in a vaccine-specific conspiracy (e.g., pharmaceutical companies cover up vaccine hazards). Each item is rated on a 7-point scale, where 1 indicates: “Strongly disagree” and 7 indicates: “Strongly agree” [29].

The Vaccination Knowledge Scale (VKS) consists of nine items on the (in)effectiveness of vaccination, dangers, and necessity. Participants choose whether each statement is true or false, and the option: “I don’t know” is also available. The total number of correct answers (correct = 1, incorrect = 0, don’t know = 0) is used to determine the knowledge score. The scale has good test-retest reliability (r = 0.70) as well as a high Mokken’s reliability estimate (0.80) [30].

HPV vaccination intention was measured using the following three items: “I intend to get the HPV vaccination”; “I expect to be vaccinated against HPV”; and “I am very likely to get the HPV vaccine”. Items are scored on a 7-point scale, where 1 means: “Absolutely false” and 7 means: “Completely true”.

Subjective norms were assessed using four items: two items measuring injunctive normative beliefs (“Most people who mean something to me would think it very good that I get the HPV vaccine”; “Most people whose opinions are important to me expect me to get the HPV vaccine”), and two items measuring descriptive normative beliefs (“Most people like me will get the HPV vaccine”; “Most people whose opinions I care about will get the HPV vaccine”). Participants rated their agreement with each statement on a 7-point scale, with 1 indicating: “Absolutely false” and 7 indicating: “Completely true.”

Perceived behavioral control was measured using the following two items: “Whether I get vaccinated against HPV will be entirely my decision”; and “Whether I get vaccinated against HPV will depend entirely on me,” rated on a 7-point scale, where 1 indicated: “Completely false” and 7 indicated: “Completely true.”

Data analysis

To identify the determinants of vaccination intention in this study, apart from descriptive statistics and correlation analysis, multiple linear regression was also applied using the SPSS, Version 26 software. The dependent variable in this study was the HPV vaccination intention of the respondents, while the independent variables were the following: vaccination attitudes, vaccine conspiracy beliefs, vaccination knowledge, subjective norms, and perceived behavioral control. To determine the relationship between the abovementioned independent variables (vaccination attitudes, vaccine conspiracy beliefs, vaccination knowledge, subjective norms, perceived behavioral control) and the dependent variable (HPV vaccination intention of the respondents), multiple linear regression was used with a significance level of p < 0.05.

RESULTS

In total, 748 students from one high school and two elementary schools in Šabac, aged 12 to 19, participated in the study (71.3% girls; mean age = 15.78, SD = 1.50). In all, 84.9% of our respondents knew about the term HPV vaccine, and as to the way they learned about the existence of the vaccine, 35.5% learned about it at school, 23.1% from their parents, 17.1% from the media, 16.4% in some other way, while only 2.7% of the respondents found out about the vaccine from doctors.

The results show that of the total number of respondents, 4.3% were vaccinated with one dose, 5% with two doses, and only 2% with more than two doses, while 83.3% of students were not vaccinated. Respondent HPV vaccination intention was measured with the help of the following three items: “I intend to get the HPV vaccination”; “I expect to be vaccinated against HPV”; and “I am very likely to get the HPV vaccine”. The internal consistency of this scale was high (α = 0.949).

The scale that examined respondent vaccination attitudes (VAX) showed that there was a mistrust of the benefits of vaccination among the respondents, as well as concern regarding commercial profiteering. Also, respondents showed a statistically significant belief in the existence of a vaccine conspiracy, and in our study, the internal consistency of the Vaccine Conspiracy Beliefs Scale (VCBS) was strong in this sample (α = 0.923).

Subjective norms were assessed using four items: two measuring injunctive normative beliefs (“Most people who mean something to me would think it very good that I get the HPV vaccine”; “Most people whose opinions are important to me expect me to get the HPV vaccine”), and two to measuring descriptive normative beliefs (“Most people like me will get the HPV vaccine”; “Most people whose opinions I care about will get the HPV vaccine”). Internal consistency reliability was satisfactory in the current sample (α = 0.870).

Perceived behavioral control was measured using the following two items: “Whether I get vaccinated against HPV will be entirely my decision”; and “Whether I get the HPV vaccine will be entirely up to me”. The correlation between these two items was quite strong and positive (r = 0.796), and the Spearman-Brown reliability coefficient was 0.886. The percentage of missing data was minimal (3.45%), and the missing data were addressed using a multiple imputation approach. G*Power software was used to assess statistical power post hoc, and its value was 1.00.

Descriptive statistics and correlations among study variables are shown in Table 1. Subjective norms and mistrust of vaccination benefits had the highest positive correlation with HPV vaccination intention, while vaccination conspiracy beliefs had the highest negative correlation. The following variables: HPV vaccination intention, subjective norms, behavioral control, mistrust of vaccine benefits, and concern about unforeseen future effects had mean values higher than the theoretical mean, while the remaining variables had mean values close to the theoretical mean.

Table 1. Descriptive statistics and correlation among study variables

Table 1. Descriptive statistics and correlation among study variables

Multiple regression analysis

To examine the predictive model in explaining young people’s HPV vaccination intention, multiple linear regression was applied (Table 2). The model explains 66% of youth HPV vaccination intentions. The strongest predictor of young people’s intention to get vaccinated against HPV are subjective norms (β = 0.605, p < 0.001), i.e., social pressure from peers and other persons significant to the respondents. Mistrust of the benefits of vaccination (β = -0.235, p < 0.001), concern about commercial profiteering (β = -0.080, p < 0.05), and vaccine conspiracy beliefs (β = -0.077, p < 0.01) had a significantly smaller but statistically significant contribution in explaining vaccination intention.

Table 2. Multiple regression analysis

Table 2. Multiple regression analysis

DISCUSSION

In this study, we examined the determinants of HPV vaccination intention in a student population. Examining attitudes is an important step in predicting young people’s behavior regarding their plans for vaccination against HPV, which according to research can be the cause of cancers of various localizations [1] and represents one of the leading public health problems, especially in developing countries [5],[6].

Since 2006, vaccines against human papillomavirus (HPV) have been available in Europe, but the coverage of their application varies amongst countries [31]. A study examining the preparedness to achieve the goals of the World Health Organization (WHO) global strategy for HPV vaccination and cervical screening (Global Strategy to Accelerate the Elimination of Cervical Cancer as a Public Health Problem) in eighteen Eastern European and Central Asian countries found that only Turkmenistan and Uzbekistan managed to reach the goal set by WHO, which is 90% of fully vaccinated girls by the age of 15 years [31].

Research has confirmed the clinical effectiveness of the vaccine against certain types of this virus responsible for invasive cervical cancer (the fifth most frequent form of cancer in the Republic of Serbia) [8], as well as for cervical, vulvovaginal, and anal precancer [32]. Despite the evidence of the effectiveness of HPV vaccines, the percentage of HPV vaccine coverage in certain countries is not optimal, which is also the case in our country. According to the recommendations of the National Program of Mandatory and Recommended Immunization of Serbia, the vaccine against human papillomavirus (HPV) infection, intended for children and adolescents aged 9 – 19 years, was not included in the mandatory immunization schedule [19], and according to the findings of a recent study, it is not being sufficiently promoted [30], which may be one of the reasons affecting the low rate of vaccinated subjects.

In our study, subjective norms and mistrust of the benefits of vaccination were singled out as the most significant predictors of the HPV vaccination intention. Respondents in our study confirm that people whose opinions they value influence their attitudes and intentions to get vaccinated against HPV. Similar results were reported by a study conducted in the USA, which points out that social influence, especially the influence of peers, can largely generate attitudes towards the HPV vaccine. The abovementioned study indicates that respondents whose friends were vaccinated with the HPV vaccine expressed a two times higher intention to get vaccinated. Also, the opinion of parents in the American research proved to be very important, because the respondents who were advised by their parents to get vaccinated expressed a two times higher intention to get vaccinated with the HPV vaccine [33].

Apart from the opinion of peers and parents, the vaccination status of the partner has a significant influence on attitudes about vaccination, as confirmed by a study conducted among young people in Kentucky [34]. The abovementioned study indicated that the preference for the respondent’s partner to be vaccinated against HPV predicted positive attitudes and acceptance of the vaccine, while the partner’s lack of preference for vaccination resulted in a negative attitude and intention to get vaccinated [34]. Considering that we live in a time that relies heavily on digital media, it is not surprising that the results of a recent survey conducted in Slovenia, which examined the attitudes of medical students regarding the HPV vaccine, indicate that the majority of respondents believe that information obtained on the Internet has the greatest influence on vaccination intention [35]. Identifying the mentioned factors can be used largely in the creation of future interventions that will help in the formation of attitudes toward HPV immunization.

The results of our study highlight, as another significant predictive factor, the mistrust of adolescents in the benefits of vaccination, which agrees with the findings of a study conducted in Italy that indicates that 38.1% of respondents doubt the usefulness of the vaccine [36]. In contrast, the results of a study conducted in Turkey indicate that almost half of the respondents believe that the vaccine is beneficial and provides protection against cancer, but even so, only 4.3% of the respondents in the aforementioned study received the vaccine against human papillomavirus [37]. The differences in attitudes may stem from the fact that the study in Turkey included older age groups, while our study examined the attitudes of adolescents. The similarity is reflected in the fact that in our study only 2% of respondents were vaccinated with more than two doses of the vaccine.

In addition to mistrust of the benefits of the vaccine, a statistically significant contribution to explaining the HPV vaccination intention in our study lies in the fact that respondents also reported concerns about commercial profiteering, as well as beliefs about a vaccine conspiracy. Previous studies confirm our results indicating the existence of complex factors, most often psychological or psychosocial in nature, that can contribute to a person’s intention to get vaccinated [38], for example, general mistrust of vaccines, conspiratorial beliefs about vaccination, and the like [39]. Such attitudes were greatly influenced by the recent epidemic of COVID-19, when we were continuously exposed to various unverified information regarding vaccines, which were marketed to the public via the Internet and various social networks, allowing opponents of vaccination (the so-called anti-vaxxers ) to be more active [35],[38],[39],[40].

The lack of timely and clear information, as well as the use of unreliable sources, can greatly influence HPV vaccination intention in adolescents. In our study, although 84.9% of respondents know about the term HPV vaccine, 35.5% of them received information about the existence of the vaccine at school, 17.1% got the information from the media, 16.4% found it in some other way, and only 2.7% obtained this information from doctors. Similar data are reported by the results of other studies [33],[35],[37]. Considering the evidence that the recommendations of doctors and other health workers, as service providers, can positively influence attitudes about HPV immunization [20],[41],[42], future interventions should be aimed at increased involvement of health workers in educating the public about the importance of preventing malignant diseases caused by the HPV virus, as well as in raising awareness about the effectiveness of the HPV vaccine.

CONCLUSION

Although this study has certain limitations, in terms of the use of a convenience sample, as well as the possibility that respondents gave answers they felt to be desirable, the research identified key aspects of mistrust towards HPV immunization. The most dominant are doubts regarding the benefits of the vaccine, followed by conspiratorial beliefs about vaccines, but also the existence of concerns about commercial profiteering. Identifying the key aspects of mistrust towards vaccination gives the possibility of planning educational health interventions and directing them towards the identified areas. The study also provides insight into the important fact that young people are susceptible to the influence exerted by their environment and that subjective norms play an important role in forming attitudes about vaccination against the HPV virus, which can be used in creating campaigns in the future.

Authors’ statement of originality

This study has not been previously published, submitted, or accepted for publishing, in whole or in part, in any other scientific journal.

  • Conflict of interest:
    None declared.

Informations

March 2024

Pages 44-55
  • Keywords:
    human papillomavirus, vaccination, adolescents
  • Received:
    10 December 2023
  • Revised:
    04 January 2024
  • Accepted:
    01 February 2024
  • Online first:
    25 March 2024
  • DOI:
  • Cite this article:
    Milošević Gačević M, Petrović S. Determinants of the human papillomavirus (HPV) vaccination intention among students. Serbian Journal of the Medical Chamber. 2024;5(1):44-55. doi: 10.5937/smclk5-48169
Corresponding author

Marijana Milošević Gačević
Secondary Medical School
Dr Andra Jovanović 9 Cara Dušana Street, 15000 Šabac, Serbia
E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.


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33. McLendon L, Puckett J, Green C, James J, Head KJ, Yun Lee H, et al. Factors associated with HPV vaccination initiation among United States college students. Hum Vaccin Immunother. 2021 Apr 3;17(4):1033-1043. doi:10.1080/21 645515.2020.1847583. [CROSSREF]

34. LaJoie AS, Kerr JC, Clover RD, Harper DM. Influencers and preference predictors of HPV vaccine uptake among US male and female young adult college students. Papillomavirus Res. 2018 Jun;5:114-121.  doi: 10.1016/j. pvr.2018.03.007. [CROSSREF]

35. Troha M, Šterbenc A, Mlaker M, Poljak M. Human papillomavirus (HPV) infection and vaccination: knowledge and attitudes among healthcare professionals and the general public in Slovenia. Acta Dermatovenerol Alp Pannonica Adriat. 2018 Jun;27(2):59-64. doi: 10.15570/actaapa.2018.14. [HTTP]

36. Pelullo CP, Esposito MR, Di Giuseppe G. Human Papillomavirus Infection and Vaccination: Knowledge and Attitudes among Nursing Students in Italy. Int J Environ Res Public Health. 2019 May 19;16(10):1770. doi: 10.3390/ ijerph16101770. [CROSSREF]

37. Aynaci G, Guksu Z. Awareness of HPV and HPV vaccination in undergraduate students in the North West region of Turkey: Near future outlook. J Infect Dev Ctries. 2019 Jun 30;13(6):516-525. doi: 10.3855/jidc.11405. [CROSSREF]

38. Sociopsihološki aspekti vakcinacije protiv COVID-19 kod mladih u Vojvodini. Filozofski fakultet, Univerzitet u Novom Sadu. Jun 2023. [Internet]. Dostupno na:https://www.researchgate.net/publication/371322326_Sociopsiholoski_aspekti_vakcinacije_protiv_COVID-19_kod_mladih_u_Vojvodini#fullTextFileContent [HTTP]

39. Murphy J, Vallières F, Bentall RP, Shevlin M, McBride O, Hartman TK, et al. Psychological characteristics associated with COVID-19 vaccine hesitancy and resistance in Ireland and the United Kingdom. Nat Commun. 2021 Jan 4;12(1):29. doi: 10.1038/s41467-020-20226-9. [CROSSREF]

40. Patel PR, Berenson AB. Sources of HPV vaccine hesitancy in parents. Hum Vaccin Immunother. 2013 Dec;9(12):2649-53. doi: 10.4161/hv.26224. [CROSSREF]

41. Kim HW, Lee EJ, Lee YJ, Kim SY, Jin YJ, Kim Y, et al. Knowledge, attitudes, and perceptions associated with HPV vaccination among female Korean and Chinese university students. BMC Womens Health. 2022 Feb 23;22(1):51.  doi: 10.1186/s12905-022-01624-1. [CROSSREF]

42. Sanftenberg L, Roggendorf H, Babucke M, Breckwoldt J, Gaertner B, Hetzer B, et al. Medical students’ knowledge and attitudes regarding vaccination against measles, influenza and HPV. An international multicenter study. J Prev Med Hyg. 2020 Jul 4;61(2):E181-E185.  doi: 10.15167/2421-4248/ jpmh2020.61.2.1308. [CROSSREF]


REFERENCES

1. de Martel C, Georges D, Bray F, Ferlay J, Clifford GM. Global burden of cancer attributable to infections in 2018: a worldwide incidence analysis. Lancet Glob Health. 2020 Feb;8(2):e180-e190. doi: 10.1016/S2214-109X(19)30488-7. [CROSSREF]

2. Ferenczy A, Franco E. Persistent human papillomavirus infection and cervical neoplasia. Lancet Oncol. 2002 Jan;3(1):11-6. doi: 10.1016/s1470- 2045(01)00617-9. [CROSSREF]

3. Doorbar J. Host control of human papillomavirus infection and disease. Best Pract Res Clin Obstet Gynaecol. 2018 Feb;47:27-41. doi: 10.1016/j.bpobgyn.2017.08.001. [CROSSREF]

4. Burd EM. Human papillomavirus and cervical cancer. Clin Microbiol Rev. 2003 Jan;16(1):1-17. doi: 10.1128/CMR.16.1.1-17.2003. [CROSSREF]

5. Crosbie EJ, Einstein MH, Franceschi S, Kitchener HC. Human papillomavirus and cervical cancer. Lancet. 2013 Sep 7;382(9895):889-99. doi: 10.1016/ S0140-6736(13)60022-7. [CROSSREF]

6. LaMontagne DS, Bloem PJN, Brotherton JML, Gallagher KE, Badiane O, Ndiaye C. Progress in HPV vaccination in low- and lower-middle-income countries. Int J Gynaecol Obstet. 2017 Jul;138 Suppl 1:7-14. doi: 10.1002/ijgo.12186. [CROSSREF]

7. Serrano B, Brotons M, Bosch FX, Bruni L. Epidemiology and burden of HPV-related disease. Best Pract Res Clin Obstet Gynaecol. 2018 Feb;47:14-26. doi: 10.1016/j.bpobgyn.2017.08.006. [CROSSREF]

8. HPV Information Centre. Human Papillomavirus and Related Diseases Report Serbia. 2023 March. [Internet]. [Pristupljeno: 25. 8. 2023.] Dostupno na: https://hpvcentre.net/statistics/reports/SRB.pdf [HTTP]

9. Marković T, Prevencija karcinoma grlića materice. Inspirijum, 2014 Aug: 10:4- 13. [Internet]. Dostupno na: https://scindeks-clanci.ceon.rs/data/pdf/2217-656X/2014/2217-656X1410004M.pdf [HTTP]

10. Harper DM, Paavonen J. Age for HPV vaccination. Vaccine. 2008 Mar 14;26 Suppl 1:A7-11.  doi: 10.1016/j.vaccine.2008.01.013. [CROSSREF]

11. Markowitz LE, Tsu V, Deeks SL, Cubie H, Wang SA, Vicari AS, et al. Human papillomavirus vaccine introduction--the first five years. Vaccine. 2012 Nov 20;30 Suppl 5:F139-48.  doi: 10.1016/j.vaccine.2012.05.039. [CROSSREF]

12. Markowitz LE, Liu G, Hariri S, Steinau M, Dunne EF, Unger ER. Prevalence of HPV After Introduction of the Vaccination Program in the United States. Pediatrics. 2016 Mar;137(3):e20151968.  doi: 10.1542/peds.2015-1968. [CROSSREF]

13. Bruni L, Saura-Lázaro A, Montoliu A, Brotons M, Alemany L, Diallo MS, et al. HPV vaccination introduction worldwide and WHO and UNICEF estimates of national HPV immunization coverage 2010-2019. Prev Med. 2021 Mar;144:106399.  doi: 10.1016/j.ypmed.2020.106399. [CROSSREF]

14. Centers for Disease Control and Prevention. HPV Vaccination Recommendations, 2021 Nov. [Internet]. [Pristupljeno: 17. 7. 2023.]. Dostupno na: https:// www.cdc.gov/vaccines/vpd/hpv/hcp/recommendations.html [HTTP]

15. Block SL, Nolan T, Sattler C, Barr E, Giacoletti KE, Marchant CD, et al. Protocol 016 Study Group. Comparison of the immunogenicity and reactogenicity of a prophylactic quadrivalent human papillomavirus (types 6, 11, 16, and 18) L1 virus-like particle vaccine in male and female adolescents and young adult women. Pediatrics. 2006 Nov;118(5):2135-45. doi: 10.1542/peds.2006-0461. [CROSSREF]

16. Petäjä T, Keränen H, Karppa T, Kawa A, Lantela S, Siitari-Mattila M, et al. Immunogenicity and safety of human papillomavirus (HPV)-16/18 AS04-adjuvanted vaccine in healthy boys aged 10-18 years. J Adolesc Health. 2009 Jan;44(1):33-40.  doi: 10.1016/j.jadohealth.2008.10.002. [CROSSREF]

17. World Health Organization. Meeting of the Strategic Advisory Group of Experts on Immunization, April 2022: conclusions and recommendations, Weekly Epidemiological Record = Relevé épidémiologique hebdomadaire, 97 (24): 261 – 276. [Internet]. [Pristupljeno: 17. 7. 2023.]. Dostupno na: https://www.alims.gov.rs/humani-lekovi/pretrazivanje-humanih-lekova/?id=399657 [HTTP]

18. ALIMS. Agencija za lekove i medicinska sredstva Srbije. Pretraživanje humanih lekova, 2019. [Internet]. [Pristupljeno: 25. 8. 2023.]. Dostupno na:https://www.alims.gov.rs/humani-lekovi/pretrazivanje-humanih-lekova/?id=399657 [HTTP]

19. Zakon o zaštiti stanovništva od zaraznih bolesti: 15/2016-31, 68/2020-4, 136/2020-3. [Internet]. [Pristupljeno: 25. 8. 2023.]. Dostupno na: https:// www.pravnoinformacionisistem.rs/SlGlasnikPortal/eli/rep/sgrs/skupstina/ zakon/2016/15/8/reg [HTTP]

20. Rancic NK, Miljkovic PM, Deljanin ZM, Marinkov-Zivkovic EM, Stamenkovic BN, Bojanovic MR, et al. Knowledge about HPV Infection and the HPV Vaccine among Parents in Southeastern Serbia. Medicina (Kaunas). 2022 Nov 22;58(12):1697. doi: 10.3390/medicina58121697. [CROSSREF]

21. Institut za javno zdravlje Srbije „Dr Milan Jovanović Batut”. Izveštaj o sprovedenoj imunizaciji na teritoriji republiкe Srbije u 2021. Godini. [Internet]. [Pristupljeno: 26. 10. 2023.]. Dostupno na: https://www.batut.org.rs/download/izvestaji/2022izvestajOSprovedenojImunizaciji.pdf [HTTP]

22. Institut za javno zdravlje Srbije „Dr Milan Jovanović Batut”. Kancelarija za skrining raka, [Internet]. [Pristupljeno: 26. 10. 2023.]. Dostupno na: https:// www.skriningsrbija.rs/ [HTTP]

23. Ailloud J, Branchereau M, Fall E, Juneau C, Partouche H, Bonnay S, et al. How can we improve the acceptability of vaccination against Human Papillomavirus (HPV) in France? An original qualitative study with focus groups comprising parents and school staff, interviewed separately. Vaccine. 2023 Jul 12;41(31):4594-4608.  https://doi.org/10.1016/j.vaccine.2023.05.072 [CROSSREF]

24. Mascaro V, Pileggi C, Currà A, Bianco A, Pavia M. HPV vaccination coverage and willingness to be vaccinated among 18-30-year-old students in Italy. Vaccine. 2019 May 31;37(25):3310-3316. doi: 10.1016/j.vaccine.2019.04.081. [CROSSREF]

25. Penţa MA, Crăciun IC, Băban A. The power of anticipated regret: Predictors of HPV vaccination and seasonal influenza vaccination acceptability among young Romanians. Vaccine. 2020 Feb 5;38(6):1572-1578. doi: 10.1016/j.vaccine.2019.11.042. [CROSSREF]

26. Marek E, Dergez T, Rebek-Nagy G, Kricskovics A, Kovacs K, Bozsa S, et al. Adolescents’ awareness of HPV infections and attitudes towards HPV vaccination 3 years following the introduction of the HPV vaccine in Hungary. Vaccine. 2011 Nov 3;29(47):8591-8.  doi: 10.1016/j.vaccine.2011.09.018. [CROSSREF]

27. Marić G, Birčanin Đ, Kisić V, Dotlić J, Zarić M, Kisić-Tepavčević D, et al. Parental perspective on human papillomavirus (HPV) vaccination in Serbia: Knowledge, attitudes and practice. Sex Reprod Healthc. 2018 Jun;16:192-198.  doi: 10.1016/j.srhc.2018.04.010. [CROSSREF]

28. Martin LR, Petrie KJ. Understanding the Dimensions of Anti-Vaccination Attitudes: the Vaccination Attitudes Examination (VAX) Scale. Ann Behav Med. 2017 Oct;51(5):652-660.  doi: 10.1007/s12160-017-9888-y. [CROSSREF]

29. Shapiro GK, Holding A, Perez S, Amsel R, Rosberger Z. Validation of the vaccine conspiracy beliefs scale. Papillomavirus Res. 2016 Dec;2:167-172.  doi: 10.1016/j.pvr.2016.09.001. [CROSSREF]

30. Zingg A, Siegrist M. Measuring people’s knowledge about vaccination: Developing a one-dimensional scale.  Vaccine. 2012;30:3771-7. doi: 10.1016/j. vaccine.2012.03.014. [CROSSREF]

31. Davies P, Aluloski I, Aluloski D, Brcanski J, Davidzenka A, Durdyeva A, et al. HPV Vaccination and Cervical Cancer Screening Policies and Practices in 18 Countries, Territories and Entities across Eastern Europe and Central Asia. Asian Pac J Cancer Prev. 2023 May 1;24(5):1781-1788.  doi: 10.31557/APJCP.2023.24.5.1781. [CROSSREF]

32. Joura EA, Kyrgiou M, Bosch FX, Kesic V, Niemenen P, Redman CW, et al. Human papillomavirus vaccination: The ESGO-EFC position paper of the European society of Gynaecologic Oncology and the European Federation for colposcopy. Eur J Cancer. 2019 Jul;116:21-26. doi: 10.1016/j.ejca.2019.04.032. [CROSSREF]

33. McLendon L, Puckett J, Green C, James J, Head KJ, Yun Lee H, et al. Factors associated with HPV vaccination initiation among United States college students. Hum Vaccin Immunother. 2021 Apr 3;17(4):1033-1043. doi:10.1080/21 645515.2020.1847583. [CROSSREF]

34. LaJoie AS, Kerr JC, Clover RD, Harper DM. Influencers and preference predictors of HPV vaccine uptake among US male and female young adult college students. Papillomavirus Res. 2018 Jun;5:114-121.  doi: 10.1016/j. pvr.2018.03.007. [CROSSREF]

35. Troha M, Šterbenc A, Mlaker M, Poljak M. Human papillomavirus (HPV) infection and vaccination: knowledge and attitudes among healthcare professionals and the general public in Slovenia. Acta Dermatovenerol Alp Pannonica Adriat. 2018 Jun;27(2):59-64. doi: 10.15570/actaapa.2018.14. [HTTP]

36. Pelullo CP, Esposito MR, Di Giuseppe G. Human Papillomavirus Infection and Vaccination: Knowledge and Attitudes among Nursing Students in Italy. Int J Environ Res Public Health. 2019 May 19;16(10):1770. doi: 10.3390/ ijerph16101770. [CROSSREF]

37. Aynaci G, Guksu Z. Awareness of HPV and HPV vaccination in undergraduate students in the North West region of Turkey: Near future outlook. J Infect Dev Ctries. 2019 Jun 30;13(6):516-525. doi: 10.3855/jidc.11405. [CROSSREF]

38. Sociopsihološki aspekti vakcinacije protiv COVID-19 kod mladih u Vojvodini. Filozofski fakultet, Univerzitet u Novom Sadu. Jun 2023. [Internet]. Dostupno na:https://www.researchgate.net/publication/371322326_Sociopsiholoski_aspekti_vakcinacije_protiv_COVID-19_kod_mladih_u_Vojvodini#fullTextFileContent [HTTP]

39. Murphy J, Vallières F, Bentall RP, Shevlin M, McBride O, Hartman TK, et al. Psychological characteristics associated with COVID-19 vaccine hesitancy and resistance in Ireland and the United Kingdom. Nat Commun. 2021 Jan 4;12(1):29. doi: 10.1038/s41467-020-20226-9. [CROSSREF]

40. Patel PR, Berenson AB. Sources of HPV vaccine hesitancy in parents. Hum Vaccin Immunother. 2013 Dec;9(12):2649-53. doi: 10.4161/hv.26224. [CROSSREF]

41. Kim HW, Lee EJ, Lee YJ, Kim SY, Jin YJ, Kim Y, et al. Knowledge, attitudes, and perceptions associated with HPV vaccination among female Korean and Chinese university students. BMC Womens Health. 2022 Feb 23;22(1):51.  doi: 10.1186/s12905-022-01624-1. [CROSSREF]

42. Sanftenberg L, Roggendorf H, Babucke M, Breckwoldt J, Gaertner B, Hetzer B, et al. Medical students’ knowledge and attitudes regarding vaccination against measles, influenza and HPV. An international multicenter study. J Prev Med Hyg. 2020 Jul 4;61(2):E181-E185.  doi: 10.15167/2421-4248/ jpmh2020.61.2.1308. [CROSSREF]

1. de Martel C, Georges D, Bray F, Ferlay J, Clifford GM. Global burden of cancer attributable to infections in 2018: a worldwide incidence analysis. Lancet Glob Health. 2020 Feb;8(2):e180-e190. doi: 10.1016/S2214-109X(19)30488-7. [CROSSREF]

2. Ferenczy A, Franco E. Persistent human papillomavirus infection and cervical neoplasia. Lancet Oncol. 2002 Jan;3(1):11-6. doi: 10.1016/s1470- 2045(01)00617-9. [CROSSREF]

3. Doorbar J. Host control of human papillomavirus infection and disease. Best Pract Res Clin Obstet Gynaecol. 2018 Feb;47:27-41. doi: 10.1016/j.bpobgyn.2017.08.001. [CROSSREF]

4. Burd EM. Human papillomavirus and cervical cancer. Clin Microbiol Rev. 2003 Jan;16(1):1-17. doi: 10.1128/CMR.16.1.1-17.2003. [CROSSREF]

5. Crosbie EJ, Einstein MH, Franceschi S, Kitchener HC. Human papillomavirus and cervical cancer. Lancet. 2013 Sep 7;382(9895):889-99. doi: 10.1016/ S0140-6736(13)60022-7. [CROSSREF]

6. LaMontagne DS, Bloem PJN, Brotherton JML, Gallagher KE, Badiane O, Ndiaye C. Progress in HPV vaccination in low- and lower-middle-income countries. Int J Gynaecol Obstet. 2017 Jul;138 Suppl 1:7-14. doi: 10.1002/ijgo.12186. [CROSSREF]

7. Serrano B, Brotons M, Bosch FX, Bruni L. Epidemiology and burden of HPV-related disease. Best Pract Res Clin Obstet Gynaecol. 2018 Feb;47:14-26. doi: 10.1016/j.bpobgyn.2017.08.006. [CROSSREF]

8. HPV Information Centre. Human Papillomavirus and Related Diseases Report Serbia. 2023 March. [Internet]. [Pristupljeno: 25. 8. 2023.] Dostupno na: https://hpvcentre.net/statistics/reports/SRB.pdf [HTTP]

9. Marković T, Prevencija karcinoma grlića materice. Inspirijum, 2014 Aug: 10:4- 13. [Internet]. Dostupno na: https://scindeks-clanci.ceon.rs/data/pdf/2217-656X/2014/2217-656X1410004M.pdf [HTTP]

10. Harper DM, Paavonen J. Age for HPV vaccination. Vaccine. 2008 Mar 14;26 Suppl 1:A7-11.  doi: 10.1016/j.vaccine.2008.01.013. [CROSSREF]

11. Markowitz LE, Tsu V, Deeks SL, Cubie H, Wang SA, Vicari AS, et al. Human papillomavirus vaccine introduction--the first five years. Vaccine. 2012 Nov 20;30 Suppl 5:F139-48.  doi: 10.1016/j.vaccine.2012.05.039. [CROSSREF]

12. Markowitz LE, Liu G, Hariri S, Steinau M, Dunne EF, Unger ER. Prevalence of HPV After Introduction of the Vaccination Program in the United States. Pediatrics. 2016 Mar;137(3):e20151968.  doi: 10.1542/peds.2015-1968. [CROSSREF]

13. Bruni L, Saura-Lázaro A, Montoliu A, Brotons M, Alemany L, Diallo MS, et al. HPV vaccination introduction worldwide and WHO and UNICEF estimates of national HPV immunization coverage 2010-2019. Prev Med. 2021 Mar;144:106399.  doi: 10.1016/j.ypmed.2020.106399. [CROSSREF]

14. Centers for Disease Control and Prevention. HPV Vaccination Recommendations, 2021 Nov. [Internet]. [Pristupljeno: 17. 7. 2023.]. Dostupno na: https:// www.cdc.gov/vaccines/vpd/hpv/hcp/recommendations.html [HTTP]

15. Block SL, Nolan T, Sattler C, Barr E, Giacoletti KE, Marchant CD, et al. Protocol 016 Study Group. Comparison of the immunogenicity and reactogenicity of a prophylactic quadrivalent human papillomavirus (types 6, 11, 16, and 18) L1 virus-like particle vaccine in male and female adolescents and young adult women. Pediatrics. 2006 Nov;118(5):2135-45. doi: 10.1542/peds.2006-0461. [CROSSREF]

16. Petäjä T, Keränen H, Karppa T, Kawa A, Lantela S, Siitari-Mattila M, et al. Immunogenicity and safety of human papillomavirus (HPV)-16/18 AS04-adjuvanted vaccine in healthy boys aged 10-18 years. J Adolesc Health. 2009 Jan;44(1):33-40.  doi: 10.1016/j.jadohealth.2008.10.002. [CROSSREF]

17. World Health Organization. Meeting of the Strategic Advisory Group of Experts on Immunization, April 2022: conclusions and recommendations, Weekly Epidemiological Record = Relevé épidémiologique hebdomadaire, 97 (24): 261 – 276. [Internet]. [Pristupljeno: 17. 7. 2023.]. Dostupno na: https://www.alims.gov.rs/humani-lekovi/pretrazivanje-humanih-lekova/?id=399657 [HTTP]

18. ALIMS. Agencija za lekove i medicinska sredstva Srbije. Pretraživanje humanih lekova, 2019. [Internet]. [Pristupljeno: 25. 8. 2023.]. Dostupno na:https://www.alims.gov.rs/humani-lekovi/pretrazivanje-humanih-lekova/?id=399657 [HTTP]

19. Zakon o zaštiti stanovništva od zaraznih bolesti: 15/2016-31, 68/2020-4, 136/2020-3. [Internet]. [Pristupljeno: 25. 8. 2023.]. Dostupno na: https:// www.pravnoinformacionisistem.rs/SlGlasnikPortal/eli/rep/sgrs/skupstina/ zakon/2016/15/8/reg [HTTP]

20. Rancic NK, Miljkovic PM, Deljanin ZM, Marinkov-Zivkovic EM, Stamenkovic BN, Bojanovic MR, et al. Knowledge about HPV Infection and the HPV Vaccine among Parents in Southeastern Serbia. Medicina (Kaunas). 2022 Nov 22;58(12):1697. doi: 10.3390/medicina58121697. [CROSSREF]

21. Institut za javno zdravlje Srbije „Dr Milan Jovanović Batut”. Izveštaj o sprovedenoj imunizaciji na teritoriji republiкe Srbije u 2021. Godini. [Internet]. [Pristupljeno: 26. 10. 2023.]. Dostupno na: https://www.batut.org.rs/download/izvestaji/2022izvestajOSprovedenojImunizaciji.pdf [HTTP]

22. Institut za javno zdravlje Srbije „Dr Milan Jovanović Batut”. Kancelarija za skrining raka, [Internet]. [Pristupljeno: 26. 10. 2023.]. Dostupno na: https:// www.skriningsrbija.rs/ [HTTP]

23. Ailloud J, Branchereau M, Fall E, Juneau C, Partouche H, Bonnay S, et al. How can we improve the acceptability of vaccination against Human Papillomavirus (HPV) in France? An original qualitative study with focus groups comprising parents and school staff, interviewed separately. Vaccine. 2023 Jul 12;41(31):4594-4608.  https://doi.org/10.1016/j.vaccine.2023.05.072 [CROSSREF]

24. Mascaro V, Pileggi C, Currà A, Bianco A, Pavia M. HPV vaccination coverage and willingness to be vaccinated among 18-30-year-old students in Italy. Vaccine. 2019 May 31;37(25):3310-3316. doi: 10.1016/j.vaccine.2019.04.081. [CROSSREF]

25. Penţa MA, Crăciun IC, Băban A. The power of anticipated regret: Predictors of HPV vaccination and seasonal influenza vaccination acceptability among young Romanians. Vaccine. 2020 Feb 5;38(6):1572-1578. doi: 10.1016/j.vaccine.2019.11.042. [CROSSREF]

26. Marek E, Dergez T, Rebek-Nagy G, Kricskovics A, Kovacs K, Bozsa S, et al. Adolescents’ awareness of HPV infections and attitudes towards HPV vaccination 3 years following the introduction of the HPV vaccine in Hungary. Vaccine. 2011 Nov 3;29(47):8591-8.  doi: 10.1016/j.vaccine.2011.09.018. [CROSSREF]

27. Marić G, Birčanin Đ, Kisić V, Dotlić J, Zarić M, Kisić-Tepavčević D, et al. Parental perspective on human papillomavirus (HPV) vaccination in Serbia: Knowledge, attitudes and practice. Sex Reprod Healthc. 2018 Jun;16:192-198.  doi: 10.1016/j.srhc.2018.04.010. [CROSSREF]

28. Martin LR, Petrie KJ. Understanding the Dimensions of Anti-Vaccination Attitudes: the Vaccination Attitudes Examination (VAX) Scale. Ann Behav Med. 2017 Oct;51(5):652-660.  doi: 10.1007/s12160-017-9888-y. [CROSSREF]

29. Shapiro GK, Holding A, Perez S, Amsel R, Rosberger Z. Validation of the vaccine conspiracy beliefs scale. Papillomavirus Res. 2016 Dec;2:167-172.  doi: 10.1016/j.pvr.2016.09.001. [CROSSREF]

30. Zingg A, Siegrist M. Measuring people’s knowledge about vaccination: Developing a one-dimensional scale.  Vaccine. 2012;30:3771-7. doi: 10.1016/j. vaccine.2012.03.014. [CROSSREF]

31. Davies P, Aluloski I, Aluloski D, Brcanski J, Davidzenka A, Durdyeva A, et al. HPV Vaccination and Cervical Cancer Screening Policies and Practices in 18 Countries, Territories and Entities across Eastern Europe and Central Asia. Asian Pac J Cancer Prev. 2023 May 1;24(5):1781-1788.  doi: 10.31557/APJCP.2023.24.5.1781. [CROSSREF]

32. Joura EA, Kyrgiou M, Bosch FX, Kesic V, Niemenen P, Redman CW, et al. Human papillomavirus vaccination: The ESGO-EFC position paper of the European society of Gynaecologic Oncology and the European Federation for colposcopy. Eur J Cancer. 2019 Jul;116:21-26. doi: 10.1016/j.ejca.2019.04.032. [CROSSREF]

33. McLendon L, Puckett J, Green C, James J, Head KJ, Yun Lee H, et al. Factors associated with HPV vaccination initiation among United States college students. Hum Vaccin Immunother. 2021 Apr 3;17(4):1033-1043. doi:10.1080/21 645515.2020.1847583. [CROSSREF]

34. LaJoie AS, Kerr JC, Clover RD, Harper DM. Influencers and preference predictors of HPV vaccine uptake among US male and female young adult college students. Papillomavirus Res. 2018 Jun;5:114-121.  doi: 10.1016/j. pvr.2018.03.007. [CROSSREF]

35. Troha M, Šterbenc A, Mlaker M, Poljak M. Human papillomavirus (HPV) infection and vaccination: knowledge and attitudes among healthcare professionals and the general public in Slovenia. Acta Dermatovenerol Alp Pannonica Adriat. 2018 Jun;27(2):59-64. doi: 10.15570/actaapa.2018.14. [HTTP]

36. Pelullo CP, Esposito MR, Di Giuseppe G. Human Papillomavirus Infection and Vaccination: Knowledge and Attitudes among Nursing Students in Italy. Int J Environ Res Public Health. 2019 May 19;16(10):1770. doi: 10.3390/ ijerph16101770. [CROSSREF]

37. Aynaci G, Guksu Z. Awareness of HPV and HPV vaccination in undergraduate students in the North West region of Turkey: Near future outlook. J Infect Dev Ctries. 2019 Jun 30;13(6):516-525. doi: 10.3855/jidc.11405. [CROSSREF]

38. Sociopsihološki aspekti vakcinacije protiv COVID-19 kod mladih u Vojvodini. Filozofski fakultet, Univerzitet u Novom Sadu. Jun 2023. [Internet]. Dostupno na:https://www.researchgate.net/publication/371322326_Sociopsiholoski_aspekti_vakcinacije_protiv_COVID-19_kod_mladih_u_Vojvodini#fullTextFileContent [HTTP]

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