Geospatial mapping of public sentiment and infodemic on human papillomavirus vaccination in India: An indication to formulation of strategies for effective implementation

ABSTRACT

The implementation of Human Papillomavirus (HPV) vaccination is crucial for eliminating cervical cancer in India. The infodemic, characterised by misleading information, could hinder the successful implementation of the initiative. Misinformation related to the HPV vaccine, such as rumours, has been reported and circulated, contributing to an alarming pattern of vaccine hesitancy observed on social media. This study aimed to identify the public sentiment towards HPV vaccination based on the ‘Behavioral and Social Drivers (BeSD)’ framework through geospatial, content and sentiment analysis. A total of 1,487 tweets were extracted. After preprocessing, 1010 tweets were identified for sentiment and content analysis. The sentiments expressed towards the HPV vaccine are mixed, with a generally positive outlook on the vaccines. Within the population, there is a pervasive proliferation of misinformation, primarily focusing on vaccine safety and efficacy, contentious subjects, ethical considerations, and a prevalent sense of uncertainty in selecting the appropriate vaccine. These observations are crucial for developing targeted strategies to address public concerns and enhance vaccination rates. The insights gained from these results will guide policymakers, healthcare practitioners, and public health organisations to implement evidence-based interventions, thereby countering vaccine hesitancy and improving public health outcomes.

KEYWORDS:

• HPV vaccination
• Misinformation
• Mistrust
• Public health outcomes
• Vaccine concern
• Vaccine preventable disease

Introduction

Cervical cancer is a major global public health issue, resulting in substantial mortality and morbidity. In the GLOBOCAN Report 2020, cervical cancer is increasing, with 604,127 reported cases and 341,831 documented deaths (GLOBOCAN, 2020). The majority of cervical cancer cases occur in low and middle-income countries (LMIC) that lack Human papillomavirus (HPV) vaccination and organised screening (Shet & Bar-Zeev, 2023). In India, the situation is particularly dire, as it contributes to nearly one-fourth of the global cervical cancer burden (Bobdey et al., 2016). The country records approximately 120,000 new cervical cancer cases annually, leading to nearly 70,000 deaths (M. Singh et al., 2022; Srivastava et al., 2018), making it a significant public health challenge.

Recognising the urgency of addressing the cervical cancer burden, the Government of India has undertaken proactive steps to curb this issue. The National Program for Cancer Control emphasises primary and secondary prevention strategies, including HPV vaccination and early detection (Bhatla et al., 2021). The introduction of the HPV vaccine in one of the states as part of the Universal Immunization Programme (UIP) in 2018 marked a significant milestone (Ahmed et al., 2021). The vaccine, primarily targeting adolescent girls, aims to protect against HPV infections, thus reducing the risk of cervical cancer development in the long term (World Health Organization, 2018). Despite these efforts, implementation of the HPV vaccine is still limited; challenges related to vaccine coverage, awareness, and misinformation persist (Burki, 2023). Presently, HPV vaccination initiatives have been established at a state level in Sikkim, with pilot projects underway in two districts of Punjab. In Delhi, HPV vaccination efforts are primarily restricted to opportunistic vaccination practices (Sankaranarayanan et al., 2019). These challenges include issues related to the safety and efficacy of the vaccine, cultural and societal norms influencing vaccine acceptance, ethical concerns, and the dissemination of accurate information (Sharma, 2013). Additionally, reports of misinformation dissemination and stigmatisation have been noted globally in the context of implementing HPV vaccination (Anoushka & Parth, 2022). The circulation of misinformation catalyzes reduced vaccine uptake and heightened vaccine hesitancy, hindering the attainment of desired public health outcomes (Dhalaria et al., 2022). This can also contribute to HPV vaccine hesitancy, potentially undermining the success of the immunisation program, as evidenced by instances of misinformation during a recent large-scale vaccination campaign (Farooq & Rathore, 2021). Confronting this challenge head-on, focusing on evidence-based education and awareness campaigns that counteract misinformation becomes crucial.

In light of these considerations, and to ensure the successful implementation of the HPV vaccine in India, it is imperative to understand and address any misinformation, such as misinformation regarding the safety and effectiveness of vaccines, that may circulate, potentially hindering its adoption. Recognising the significance of HPV vaccination in alleviating the burden of cervical cancer, this study aimed to identify the public sentiment towards HPV vaccination based on the ‘Behavioral and Social Drivers (BeSD)’ framework through the utilisation of geospatial, content, and sentiment analysis (Brewer et al., 2017). The Behavioural and Social Drivers (BeSD) of the vaccination framework encompass the multitude of factors that influence individual and collective vaccination behaviours within a society (Brewer et al., 2017). The BeSD model has been utilised in various health-related contexts to understand social media and online foreign disinformation -campaigns on vaccination rates and attitudes towards vaccine safety (Wilson & Wiysonge, 2020). Twitter, as a valuable surveillance tool, is employed to identify circulating misinformation and comprehend the factors influencing the effective implementation of HPV vaccination, as evidenced by previous studies (Tsai & Wang, 2021). Identifying and addressing ongoing concerns and misinformation regarding the HPV vaccination will facilitate the development of effective strategies for the successful national implementation of the HPV vaccine and the subsequent reduction of cervical cancer incidence.

Materials and methods

The content, sentiment and geospatial analysis was performed. The research methodology utilised in this paper was not based on a predetermined workflow. We developed it based on relevant literature and selected appropriate content, sentiment and geospatial analysis methods. The methodology consists of the following steps, as shown in Figure 1.

Figure 1. Flow chart showing the analysis steps.

The data acquisition and analysis process was conducted using Python programming language. We employed various Python libraries, including Pandas, Geopandas, VADER (Valence Aware Dictionary and sEntiment Reasoner) (Hutto & Gilbert, 2015), and TextBlob (Loria, 2020). Pandas’ library was used for data manipulation and analysis, allowing us to work with structured data using DataFrames efficiently. Geopandas and GeoPy were utilised to handle geospatial data and perform geospatial analysis. To access the sentiment of the collected tweets, two sentiment libraries, VADER and TextBlob, were used. VADER is specifically designed for social media text analysis and provides a lexicon-based approach to determine the polarity score for each tweet, whereas TextBlob offers a more general natural language processing (NLP) approach.

Data acquisition

For our research, we exclusively collected tweets originating from India that contained specific keywords related to Human Papillomavirus like ‘HPV’ and ‘Human Papillomavirus’, in conjunction with terms like ‘cervical cancer’, ‘screening’, ‘prevention’, ‘vaccine’, ‘vaccination’, ‘Gardasil’, ‘Cervarix’, ‘Cervavac’, ‘pap smear’ and ‘visual inspection with acetic acid’. The data collection period spanned from November 1, 2007, to May 13, 2023. We utilised Twitter's academic research Application Programming Interface (API) v2 to access and acquire the tweets, totalling 1487 for our study (Twitter Developer Platform, 2022).

Data preprocessing

Pre-processing is the process of cleaning and preparing the text for analysis. The original tweets were first passed through an initial filtering round before pre-processing. The tweets labelled ‘is retweet’ were marked as duplicates and subsequently removed. Additional duplicates were also eliminated based on tweet ID and tweet text. The resulting dataset was then distributed among the coders for coding. The coded tweets were then pre-processed in several steps: (i) Tweets categorised as ‘irrelevant’ during the coding process were excluded from the dataset as noisy and irrelevant data. (ii) Aspects of the tweets like hashtags, mentions, links (URL’s and hyperlinks), emails, numeric data and, tabs and blank spaces were removed as they don’t contribute much to the sentiment of data. For word frequency analysis, the tweets were further tokenised and stopwords removed. (iii) Only tweets in the English language were considered. Finally, the pre-processed tweets were annotated with three labels: Positive, Negative and Neutral. After data preprocessing, 1010 annotated tweets were used for performing word frequency and sentiment analysis.

For geospatial analysis, the dataset mapped with sentiment scores was considered. The tweets without user location or containing irrelevant location values were removed. Only those tweets with place/state mentioned in the user profiles were retained. In our study, the geospatial analysis primarily focuses on tweets with available ‘user location’ rather than geo-tagged tweets, as the number of geo-tagged tweets was relatively low. To geocode the user location – – i.e. update them with corresponding coordinates, we utilised geocoders from GeoPy, a Python package that utilises a web API for the conversion process (Lungu, 2019). Ultimately, a total of 683 tweets were selected for the final geo-spatial analysis.

Data analysis

The data analysis segment comprises word frequency and sentiment analysis, geospatial analysis and content analysis, as elaborated upon below.

Word Frequency and Sentiment Analysis: Word frequency plays a very significant role in sentiment analysis. It shows which words appear most frequently in the tweets. Figure 2 illustrates the most frequent words appearing in the tweets.

Figure 2. The most frequently occurring words from the tweets.

The cleaned tweets from the previous phase were submitted to VADER and TextBlob models to calculate the sentiment scores for each tweet in the dataset. Both models provided polarity scores (compound score in case of VADER) within the range of [−1, + 1], where +1 indicates extremely positive sentiment, – 1 indicates extremely negative sentiment, and 0 indicates a neutral polarity. Subsequently, these sentiment scores were mapped into three classes: tweets with a polarity range of (0, 1] were categorised as positive sentiment, those with a range of [−1, 0) were categorised as negative sentiment, and tweets with a polarity of 0.0 were categorised as neutral sentiment. To assess the models’ effectiveness, metrics like macro_F1 score (the harmonic mean of macro-averaged precision and recall) and classification accuracy were used.

Geospatial analysis

‘Geospatial analysis is a form of computational analysis that leverages geographic information, spatial data, location data, and increasingly, high-resolution imagery, computer vision, and other forms of AI to extract structured data that can be used for specific applications and industries’ (CAPE Analytics, n.d.). This analysis was conducted to identify the places where the tweets originated and the sentiment distribution of tweets across the states. The geocoders allow us to get geographic coordinates from textual location, called forward geocoding. Likewise, reverse geocoding is finding textual location from geographic coordinates.

The geospatial analysis was carried out at the state level. To map tweets to their corresponding states, reverse geocoding was applied to those tweets with place names mentioned. The digital boundary of India used in the analysis was adapted from an open repository (Github, 2019; Wang et al., 2022). The coordinates originating from each specific state were aggregated, and the data was plotted on the India shape file, as depicted in Figure 5. Tweets distribution based on the polarity obtained from the VADER model was plotted as shown in Figure 6.

Content analysis

After the initial filtering process, 1,011 tweets were utilised for content analysis to strengthen the study’s analytic dependability, confirmability, and trustworthiness. Three coders each were provided with 396 tweets. Based on the ‘Behavioral and Social Drivers’ (BeSD) of the vaccination framework, the coders independently compiled a list of issues concerning factors associated with implementation (Brewer et al., 2017). The study employed a codebook to categorise the factors influencing vaccination intake as overarching themes. Specific concerns identified through the open coding process were designated coding variables within these themes. Microsoft Excel was utilised for coding the tweets.

Ethical approval

This study employed publicly accessible tweets as its data source, rendering it a secondary data collection method, thereby qualifying for exemption from ethical approval requirements.

Results

Sentiment analysis

After preprocessing, a total of 1,010 tweets underwent sentiment analysis using VADER and TextBlob. Table 1 presents the sentiment distribution, indicating the percentages of positive, negative, and neutral tweets identified within the dataset.

Table 1. Analysis results of VADER and TextBlob.

Models	Positive	Negative	Neutral
VADER	313 (30.99%)	496 (49.11%)	201 (19.90%)
TextBlob	449 (44.46%)	133 (13.17%)	428 (42.38%)

The tweets acquired from Twitter APIs are original, lacking pre-assigned labels, and showcase an uneven distribution of sentiments. To assess the performance of the sentiment analysis models, we annotated all of the extracted tweets manually. The accuracy and macro-F1 score of the analyzers are depicted in Figure 3.

Figure 3. Classification report of VADER and TextBlob.

From Figure 3, it is evident that the results obtained by the VADER and TextBlob tools exhibit some differences. The TextBlob classifier demonstrates slightly better performance for positive tweets, while VADER performs better for negative tweets. However, the TextBlob analysis shows a low proportion of negative sentiments, which could be attributed to certain words being incorrectly assigned sentiments due to limited coverage of domain-specific words, leading to deviations in sentiment scores. After closely examining the tweet labels, the classification results of the VADER method are more accurate compared to TextBlob.

The confusion matrix is depicted for two classifiers, as illustrated in Figure 4. The cells positioned along the anti-diagonal line represent the percentage of tweets accurately predicted by the classifiers.

Figure 4. Confusion Matrices for VADER and TextBlob.

Geospatial mapping of public sentiment

Figure 5 highlights the geospatial mapping to sentiment analysis reveals notable variations in HPV vaccination sentiment across different locations in India, with the highest concentration observed in Maharashtra, followed by Delhi, Haryana, Karnataka, Tamil Nadu, and other states. Nevertheless, certain states and Union Territories, namely Jharkhand, Andaman Nicobar, Manipur, and Mizoram did not report any relevant tweets.

Figure. 5. Vader sentiment distribution across India (Uptake/refusal of HPV vaccines).

Content analysis

Safety concerns

Given the introduction of the HPV vaccine as a means to counter the cervical cancer, individuals utilising social media platforms have articulated significant apprehensions pertaining to severe adverse events following immunisation (AEFI) and mortalities, protracted complications and paralysis, detrimental effects on female reproductive health and concerns about infertility, potential biohazards and prohibitions in Europe, apprehensions pertaining to safety and the presence of unethical practices, anxieties surrounding the risks and adverse effects of HPV vaccines, dissemination of inaccurate information regarding the association between the HPV vaccine and increased cancer risk, the need for reliable and affirmative information regarding the accessibility and screening for HPV, substantiated achievements and favourable responses to vaccination based on empirical evidence, reduction in disease burden and its impact on public health, and the significance of evidence-based decision-making and sustained implementation of HPV vaccination (Table 2).

Table 2. Tweets related to safety concerns, controversies and ethical issues, public sentiment and perception, vaccine confusion and information seeking, distribution, accessibility, inclusivity and vaccine effectiveness and success stories.

Determinants	Issue	Tweets
Safety Concerns	Adverse events following immunisation	‘In 2009 the Gates Foundation funded vaccination testing for Gardasil, the anti HPV vaccine in some children in India. Some of those children died, and the trial is being blamed for it. Some people also think this was a sterilisation effort. They are trending #ArrestBillGates 1/5’
Safety Concerns	Vaccination negative consequences	‘awakenindiamov: Girl Commits Suicide After #Gardasil Vaccine Destroys Her Life https://t.co/y4tCbjEQKC #vaccinegenocide’
Controversies and Ethical Issues	Legal issue	‘Top story: Lawsuit Filed Against Pharmaceutical Giant Merck on Behalf of Young Man Allegedly Injured by Gardasil • Children's Health Defense https://t.co/FRAE8Eu4WS, see more https://t.co/QfdxDNTH5K’
Public Sentiment and	Mixed attitude	‘Confusing. Are you saying failure of Gardasil vaccine may be a cause for rise in cervical cancer? https://t.co/tHhm9hfVyQ‘
Public Perception	Indian vaccine	Yes. Already 2 cervical cancer vaccine available from foreign origin (Cervarix, Gardasil). Now we have Indian vaccine which will be cheaper and affordable.
Vaccine Confusion and Information Seeking	Information dissemination	‘#CERVAVAC, It’s India’s first indigenously developed vaccine for preventing cervical cancer caused by #HPV. India emerging as a global leader in vaccine R&D #AtmanirbharBharat
Vaccine Confusion and Information Seeking	False information	‘Along with #Covid vaccination. Focus on Aids prevention is Important. I have learned that Gardasil 9 is the precise vaccine for Aids prevention. 2 shots in 6 months for under 14 both boys and girls & 3 shots in 6 months above 14 years. Original & price needs check to reach all. https://t.co/iEgsw2XzWA’
Distribution, Accessibility and, Inclusivity	Vaccine unavailability	‘No, these vaccines are not available in govt. supply yet. I wish they were because they're very expensive. Gardasil 9 costs between Rs 9000–10500 per dose. The complete course consists of 3 doses at 0, 2 and 6 months.’
Distribution, Accessibility and, Inclusivity	Enquiring vaccine availability	‘Not yet launched. Cervarix and Gardasil are mostly available all over India in major cities. May I know which area you are referring to?’
Vaccine Effectiveness and Success Stories	Advocacy for HPV vaccination	‘This #Rakshabandhan I choose to gift my sister long lasting protection against Cervical Cancer, through vaccination. #GSKIndia #Cervarix’
Vaccine Effectiveness and Success Stories	Advocacy for HPV vaccination	‘No, Parents. The HPV Vaccine Won't Encourage Your Daughter to Have Risky Sex. – Mother Jones https://t.co/Hd2GlXaBoa’
Nationalistic satisfaction	Motivation	India is a global pharmacy – 70% vaccines made in pune! @ecancer #ecancerchoosingwisely indian hpv vaccine as effective as gardasil! Fantastic work @melindagates @BillGates @IARCWHO @uicc this will truly help #eliminatecervicalcancer https://t.co/scYuLSkK5e
Safety Concerns	Allegations against pharmaceutical companies	Diseases are created to run pharma business Peace is endangered to sell weapons Females are raped to topple … https://t.co/e5RIueOCz3

Controversies and ethical issues

Individuals have brought attention to medical controversies associated with the HPV vaccination trials conducted in India. They have expressed ethical apprehensions regarding clinical trials, emphasising the need for transparency. Additionally, concerns have been raised about the significance of informed consent and access to accurate information, along with instances of vaccination occurring without consent and unethical practices in conjunction with insufficient information disclosure. Some individuals have questioned the recommendations doctors and the FDA provided, leading to lawsuits against some HPV vaccine and a loss of trust in certain HPV vaccine brands. Allegations of research fraud and scandals surrounding the HPV vaccine have been made, with people also questioning the silence exhibited by the media and labelling the HPV vaccine as a profit-driven endeavour associated with vaccine companies (Table 2).

Public sentiment

Public sentiment in India regarding the HPV vaccination manifests a variety of attitudes and concerns. There is a notable focus on the safety of the vaccine, with individuals posing questions and expressing worries. Moreover, there is strong support for those affected by HPV, coupled with criticisms directed towards the vaccine itself. The overall outlook towards the HPV vaccine is mixed, although there exists a generally positive perception of both foreign and Indian vaccines. Concerns have been raised by certain individuals regarding the affordability of the vaccine, leading to demands for subsidised rates and improved accessibility. In addition, there is a call for the inclusion of the HPV vaccine in national immunisation plans, along with a hopeful desire for the development of a cost-effective Indian vaccine. Furthermore, individuals engage in comparisons between various existing HPV vaccines and express reservations about the discontinuation of a particular vaccine (Table 2).

Public perception

Even though a substantial majority of individuals demonstrate anxiety towards HPV vaccination, a minority express endorsement for an Indian HPV vaccine and a feeling of satisfaction, demonstrating favourable dispositions towards cost-effective Indian vaccines. Advocates for HPV vaccination in India actively advocate for the significance of this vaccination and emphasise the necessity for its incorporation in the national immunisation programme (Table 2)

The public's concerns about the HPV vaccine extend to comparing existing HPV vaccines and deliberating the discontinuation of an ongoing vaccine. Although the majority of people exhibit apprehension towards HPV vaccination, there exists a small segment that supports an Indian HPV vaccine, taking pride in the development of low-cost Indian vaccines. These individuals actively advocate for HPV vaccination in India, promoting its significance and emphasising the necessity of its implementation.

Vaccine confusion and information seeking

Multiple vaccines are accessible to safeguard individuals against cervical cancer. There exists a demographic actively inquiring about alternatives to the presently accessible vaccine. This group expresses heightened apprehension due to the scarcity of general information dissemination regarding HPV vaccines, resulting in uncertainty regarding selecting an appropriate HPV vaccine. Notably, individuals within this cohort exhibit favourable attitudes towards an Indian vaccine. They seek reliable information about the testing procedures associated with Indian vaccines. Additionally, inquiries are made regarding the availability and cost of the Gardasil vaccine. A prevalent concern revolves around the excessive expense of this vaccine while simultaneously expressing a desire for an affordable Indian alternative. Furthermore, individuals note that there is no clear recommendation regarding HPV vaccination from healthcare providers (Table 2).

As there is a lack of information disclosed about the vaccines, it affected the opinion of people accepting the vaccine. Multiple speculations highlighting the side effects are being shared, and concerns have been forwarded. There are claims and concerns that the vaccine trials are flawed. However, the public also expressed a positive attitude towards vaccines, promoting their uptake and empowering individuals through education and knowledge dissemination. A portion of the population also ensures access to reliable information, addressing health literacy. Despite the negative opinion about the vaccine, a few cervical cancer vaccine awareness campaigns were also held worldwide, and people swarmed to share and promote vaccination.

Distribution, accessibility and inclusivity

The distribution and accessibility of the HPV vaccine have been the subject of concern among people, particularly in promoting vaccine availability and increasing access. One prominent issue raised is the cost of the vaccine, which has led to worries about affordability for certain individuals or communities. Recognising the importance of addressing disparities in vaccine uptake, there have been calls for strategies to enhance accessibility and affordability. These concerns have been amplified by the prevalence of HPV vaccine infodemics, which further complicate the implementation of vaccination programmes (Table 2).

There has been increased attention towards the need to tackle HPV risk in distinct population groups (such as LGBTQ individuals and girls), advocating for women's health and promoting gender equality concerning HPV vaccination. Furthermore, a growing emphasis is on fostering collaboration between the healthcare and education sectors to facilitate preventive healthcare initiatives, particularly within school settings (Table 2).

Vaccine effectiveness and success stories

Within evidence-based decision-making and ongoing vaccination efforts, the commendable accomplishments attributed to HPV vaccination emerge as compelling illustrations. The amalgamation of individuals sharing their substantiated success stories highlights the undeniable efficacy of this preventive vaccine. A noticeable decline in the prevalence of HPV-related diseases is observed by embracing a proactive stance, thereby generating a significant positive impact on public health. The triumph of HPV vaccination is a testament to the steadfast adherence to evidence-based principles, culminating in establishing a healthier and more promising future for successive generations (Table 2).

Discussion

Cervical cancer is a significant global public health concern, leading to premature mortality and morbidity (GLOBOCAN, 2020). To combat this, the World Health Organization underscores the integration of HPV vaccination as a part of the comprehensive strategy to eliminate cervical cancer as a public health problem (World Health Organization, 2020). Given that India represents one-fourth of the global disease burden, integrating HPV vaccination as the comprehensive strategy for eliminating cervical cancer is increasingly becoming crucial (M. P. Singh et al., 2020). Despite the Indian government's efforts to facilitate HPV vaccination implementation, the current coverage remains constrained (Sankaranarayanan et al., 2019). A notable recent significant advancement is the Ministry of Health and Family Welfare of India's resolute determination to initiate the rollout of Human Papillomavirus (HPV) vaccination, marking a strategic milestone (Burki, 2023). In this context of the government initiative, people were highlighting diverse sentiments towards the HPV vaccine and its implementation. Therefore, this study documented the current concerns revolving around HPV vaccination in India and highlighted the different levels of policy implementation that can be adopted by utilising the BeSD framework, which encompasses four major activities: Cognitive and Emotional Processes, Social Processes, Motivation, and Practical Issues as shown in Figure 6.

Figure. 6. Adopted BeSD: A Model for Effective HPV Vaccination in India.

Thinking and feeling

Most individuals’ concerns over perceived susceptibility to disease and AEFI following HPV vaccination pose obstacles to achieving optimal vaccination coverage. Similar challenges have emerged concerning misconceptions about cancer causes and vaccine hesitancy (Paytubi et al., 2022). These concerns adversely influence individuals’ health-related behaviour and informed health decisions (World Health Organization, 2022a). Consequently, addressing these misapprehensions and countering unfounded notions becomes imperative for fostering vaccine acceptance. Such apprehension may stem from multiple factors, such as individuals’ inherent tendency to be cautious towards novel experiences, including among healthcare professionals (Safi et al., 2018). Thus, when formulating strategies, it is crucial to consider the diverse array of variables associated with vaccine hesitancy (Ebrahimi et al., 2021). In this response, promoting understanding of the risks and benefits related to HPV vaccination is essential to combat misinformation. For that, healthcare experts can play a crucial role in disseminating evidence-based information, explaining the safety measures, and highlighting the importance of vaccination for preventing HPV-related diseases. Clear communication about the potential side effects, frequency, and severity can help individuals make informed decisions. By proactively addressing these concerns, healthcare providers and authorities can establish trust and credibility, providing accurate information and personalised guidance to individuals to promote HPV vaccination (Meyer, 2015). As such confusion arises due to limited health literacy, leading to decreased healthcare service utilisation (Goto et al., 2019). Therefore, advocating interventions like ‘legal policy development, awareness campaign creation and promotion, enhancement of health-related media content, and augmentation of digital and health literacy’ can be advocated to promote positive health behaviours and bolster vaccine acceptance (World Health Organization, 2022a), given the documented significance of improved health literacy for disease management in India (Nagarjuna et al., 2023).

According to this study, mistrust towards vaccine manufacturing companies is a prevalent concern among the public. Similar concerns have been raised in other studies (Moynihan et al., 2002; Roy & Shankar, 2018), potentially decreasing vaccine acceptance. To address this lack of trust, it is suggested that responsible journalism and a meticulously designed crisis communication plan could be implemented (Yu et al., 2021). Additionally, an anti-vaccine movement has been observed, consistent with other studies that have highlighted similar concerns on social media platforms (Benoit & Mauldin, 2021). Therefore, it is of utmost importance to cultivate resilience against vaccine misinformation by enhancing public health and digital literacy (Germani & Biller-Andorno, 2022). To address this, healthcare experts can harness social media platforms to grasp ongoing concerns and devise strategies to counter misinformation, thereby mitigating mistrust. This utilisation of social media has been previously documented and recognised as an established approach (Muric et al., 2021). Furthermore, observations indicate that individuals commonly refer to the HPV vaccine as the ‘cervical cancer vaccine.’ Consequently, when formulating communication strategies, it would be prudent to customise messaging terminology that aligns with the community's existing familiarity (World Health Organization, 2023a).

Social process

Multiple sociocultural factors influence the acceptance of HPV vaccination, including the challenge individuals face in selecting the appropriate vaccine due to many choices. This uncertainty is expected and mirrors similar vaccine choice dilemmas in other vaccination processes (Pimpalgaonkar, 2021). Therefore, it's essential to improve health literacy about HPV vaccination, and effective communication plays a vital role. Employing strategies like vaccination campaigns through media platforms can adopt successful communication models used in other vaccination efforts (Elgendy & Abdelrahim, 2021).

During the study analysis, it has been observed that individuals have emphasised ethical issues and controversies surrounding HPV trials in India. Similar apprehensions concerning ethical issues and vaccine-induced mortality relating to cancer causation have likewise been reported in previous studies (Sankaranarayanan et al., 2019). Additionally, HPV vaccination and cervical cancer are linked to sexual health, a topic often stigmatised in India, possibly due to the marginalisation of women's health (Yadav & Jena, 2020), which may hinder widespread HPV vaccination efforts. This form of stigmatisation also emerged in diseases like monkeypox (mpox) (Núñez & Valdés-Ferrer, 2023). To counter these adverse perceptions concerning the vaccine and the disease, it is imperative to institute a stigma communication plan to reduce stigma. This initiative could enhance HPV vaccination acceptance (Pulerwitz et al., 2010; World Health Organization, 2022b) as risk communication approaches have proven efficacious in mitigating the stigma associated with diseases, resulting in positive outcomes.

Motivation

Amid the abundance of misinformation surrounding HPV vaccination, notable efforts by healthcare practitioners have been observed in disseminating accurate information to counter misinformation. These endeavours have effectively boosted confidence in the HPV vaccination process. This phenomenon aligns with previous research emphasising the pivotal role of healthcare personnel in health promotion (Profis & Simon-Tuval, 2016). In parallel, a subset of the population has focused on highlighting the favourable outcomes associated with the HPV vaccine. This effort highlights people supporting vaccination initiatives and increases motivation among the fellow group. Evidence from earlier studies underscores the efficacy of interventions that encourage motivation (van der Sande et al., 2023). As such, including success stories becomes imperative in the strategic promotion of HPV vaccination within the Indian context.

Additionally, the recent development of an indigenous HPV vaccine within India assumes the capacity to nurture a sense of nationalistic satisfaction and augment societal acceptance as numerous individuals have highlighted a favourable inclination towards the Indian HPV vaccine through the proclamation of it being ‘Made in India’, actively endorsing its usage. Similarly, an encouraging response was witnessed from the recent vaccination during a pandemic (UNICEF, 2021), underscoring the potential effectiveness of a comparable approach. By adopting the slogan ‘Made in India’, health authorities can foster enthusiasm among individuals to actively engage in vaccination initiatives.

Practical issues

Numerous individuals have voiced apprehensions concerning the restricted availability and accessibility of the HPV vaccine. The primary reason underlying this constraint is the high cost associated with the vaccine (Roy & Shankar, 2018), making it unaffordable for most people in economically disadvantaged countries (Gallagher et al., 2018). In response, people have called for the establishment of policy frameworks that would ensure the vaccine's integration within government healthcare infrastructure and mitigate its financial barriers.

A notable recent development in this context is the recent launch of an indigenous HPV vaccine in India, priced at a range of 200–400 INR per dose, significantly undercutting the pricing established by the Global Alliance for Vaccines and Immunization (GAVI), resolving this issues associated with affordability (Burki, 2023; (Global Alliance for Vaccines and Immunization, 2023). Concurrently, a recent significant advancement is the Ministry of Health and Family Welfare of India's resolute determination to initiate the rollout of the HPV vaccination, marking a strategic milestone to resolve the issue associated with the limited accessibility of the HPV vaccine (Burki, 2023). Additionally, the implementation of the HPV vaccination programmes can be further strengthened by integrating with Universal Health Coverage (UHC), as UHC aims to provide high-quality health services to individuals without causing a financial burden (World Health Organization, 2023b). Consequently, the availability of UHC could enhance the accessibility of HPV vaccination programmes in India.

The issues pertaining to HPV vaccination in India, as observed, highlight widespread concerns. In response, medical professionals can utilise various social media platforms to disseminate accurate information regarding HPV vaccination, emphasising its safety, efficacy, and significance in preventing cervical cancer. This utilisation of social media has been recognised to enhance health-related outreach and communication (Ventola, 2014). Engaging in interactive communication enables direct addressing of apprehensions, while collaborating with influencers extends the reach and effectively counters misinformation (Hofstra & Gommers, 2023). Crafting visually engaging content further enhances engagement, and vigilant monitoring of social media discussions enables timely identification and resolution of emerging issues. These strategies empower medical personnel to play a pivotal role in addressing vaccine hesitancy and fostering HPV vaccination uptake in India.

Conclusion

This study has brought attention to the apprehensions associated with HPV vaccination in India. The research advocates for immediate action to halt the dissemination of misinformation. Implementing an efficient educational programme and a risk communication strategy at the national and state levels is necessary to meet the WHO's threshold for cervical cancer elimination.

Strengths and limitations

The present study boasts significant strengths that contribute to a nuanced understanding of prevailing attitudes and potential strategies regarding HPV vaccination in India. The utilisation of Twitter data collected from diverse Indian states and union territories enables a comprehensive analysis, offering insights into sentiments across various demographics and geographical locations. Moreover, the accessibility of Twitter data reduces costs compared to traditional survey methods, making it a cost-effective approach for studying public sentiment on healthcare issues like vaccination. However, the study's limitations underscore the need for further investigation and refinement. Improving the representation of Twitter users, particularly to address potential biases and ensure inclusivity, is essential for enhancing the validity and generalizability of findings. Additionally, acknowledging disparities in access to technology and sparse data from specific regions is crucial for understanding the broader landscape of public sentiment. Moreover, addressing the challenge of misinformation dissemination and the influence of automated bots on vaccination stances is vital for accurately gauging public perceptions and developing targeted interventions. Furthermore, incorporating non-English language data could enrich the analysis and provide a more comprehensive understanding of diverse perspectives. Overall, while the study offers valuable insights, it also highlights important avenues for future research, particularly in addressing the identified limitations and exploring inadequately represented data realms, thereby serving as a valuable platform for further studies with similar objectives.

Authors contributions

PR, CK, PN, and HB formulated and outlined the study design. CK was responsible for Twitter data extraction and spearheaded the sentiment analysis. PR, RK, and VSD coded the data, with PR overseeing the content analysis. PR, CK, and RK drafted the initial manuscript. SP, PN, KS, and HB contributed significant feedback and participated in manuscript revisions. All authors had complete access to the study data, ensuring data integrity and analysis reliability. The final responsibility for the decision to submit for publication rested with all authors.

Ethical approval & informed consent

The tweets are available in the public domain/forum; therefore, it is considered a secondary data source and, thus, exempted from ethical approval & informed consent.

Acknowledgements

The staff of Prasanna School of Public Health (PSPH), MAHE, express sincere appreciation for the logistical support provided.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

Upon request, the data will be made accessible.