Background: Adult vaccination, crucial for preventing diseases like Hepatitis B, influenza, COVID-19, and HPV-related cancers, remains underutilized in India, particularly in rural regions like Himachal Pradesh, due to knowledge gaps, misconceptions, and access barriers. This study aimed to evaluate public awareness of adult vaccination, focusing on Hepatitis B, flu, COVID-19 boosters, and HPV, among adults in Himachal Pradesh, with an emphasis on rural communities. Materials and Methods: A descriptive, cross-sectional online survey was conducted from January to March 2025 , targeting adults aged 18–65 years in Himachal Pradesh. A bilingual (Hindi/English) questionnaire, hosted on Google Forms, assessed socio-demographic factors, vaccination knowledge, attitudes, and barriers. Using convenience sampling, 480 participants completed the survey. Data were analyzed with IBM SPSS Statistics v27.0, with knowledge scores categorized as Very Good (≥80%), Good (60–79%), Fair (40–59%), and Poor (<40%). Results: Participants, primarily aged 18–35 years (72.9%) and female (55.0%), showed moderate awareness: 80.0% recognized adult vaccines prevent serious diseases, 75.0% identified Hepatitis B’s liver disease link, and 82.9% noted cost as a barrier. Gaps existed in flu vaccine frequency (60.0%), asymptomatic Hepatitis B (64.0%), and HPV infection (62.9%). Knowledge levels were Very Good (27.9%), Good (46.0%), Fair (20.0%), and Poor (6.1%). Limited healthcare access (32.1%) highlighted rural challenges. Conclusion: While awareness of adult vaccination is improving, knowledge gaps and barriers like cost and access persist in Himachal Pradesh. Targeted education, subsidized vaccines, and rural outreach are critical to enhancing uptake and reducing disease burden.
Vaccination is a cornerstone of public health, significantly reducing morbidity and mortality from infectious diseases across all age groups. While childhood immunization programs have achieved remarkable success globally, adult vaccination remains underutilized, particularly in low- and middle-income countries like India, where awareness and uptake are hampered by knowledge gaps, misconceptions, and systemic barriers. In Himachal Pradesh, a predominantly rural state in northern India, infectious diseases such as Hepatitis B, influenza, and COVID-19 continue to pose significant health risks, exacerbated by limited healthcare infrastructure and low prioritization of adult immunization. Vaccines like Hepatitis B, flu, COVID-19 boosters, and Human Papillomavirus (HPV) are critical for adults to prevent severe outcomes, yet public understanding of their importance is often inadequate, leading to low coverage rates and persistent disease burden [1-4].
The socio-cultural and geographic context of Himachal Pradesh shapes attitudes toward adult vaccination. Rural communities, which constitute a significant portion of the state’s population, face unique challenges, including limited access to healthcare facilities, reliance on traditional health practices, and skepticism about vaccine efficacy and safety. For instance, Hepatitis B, a major cause of liver disease, has low vaccination coverage among adults despite its inclusion in India’s Universal Immunization Programme for specific groups. Similarly, influenza vaccines and COVID-19 boosters are often perceived as unnecessary or inaccessible, while HPV vaccination, primarily associated with cervical cancer prevention, suffers from low awareness among adults beyond the recommended age for adolescents. These knowledge gaps are compounded by myths, such as fears of side effects or beliefs that vaccines are only for children, which deter uptake and undermine public health efforts [5-7].
Efforts to improve adult vaccination coverage in India, including awareness campaigns and integration of vaccines into primary healthcare, have had varying success. In Himachal Pradesh, the impact of such initiatives remains underexplored, particularly in rural areas where health literacy is low, and logistical barriers like distance to clinics and cost are significant. Understanding public awareness of adult vaccines, identifying knowledge gaps, and exploring attitudes toward vaccination are crucial for designing targeted interventions that enhance uptake and reduce vaccine-preventable diseases. This study aims to evaluate the awareness of adult vaccination, focusing on Hepatitis B, flu, COVID-19 boosters, and HPV, among adults in Himachal Pradesh, with an emphasis on rural communities. By highlighting knowledge deficiencies and barriers, the research seeks to inform strategies to strengthen adult immunization programs and promote healthier communities in the region.
Study Design
A descriptive, cross-sectional online survey was conducted to assess awareness of adult vaccination (Hepatitis B, flu, COVID-19 boosters, HPV), knowledge of their importance, and perceived barriers to uptake among adults in Himachal Pradesh.
Study Area and Population
The study targeted adults aged 18–65 years residing in rural and semi-urban areas of Himachal Pradesh. Eligible participants were proficient in Hindi or English, had access to internet-enabled devices (smartphones, tablets, or computers), and provided voluntary informed consent.
Study Duration
Data collection was conducted over three months, from January to March 2025.
Sample Size and Sampling Technique
Assuming a 50% awareness level of adult vaccination (due to limited prior data), with a 95% confidence interval and a 5% margin of error, the minimum required sample size was calculated as 384. To account for potential incomplete responses, a target of 480 completed responses was set. Convenience sampling was utilized, with the survey link distributed via social media platforms (WhatsApp, Facebook, Instagram) and community networks, including local health workers, self-help groups, and Gram Panchayats.
Inclusion and Exclusion Criteria
Inclusion Criteria: Adults aged 18–65 years, residents of Himachal Pradesh, proficient in Hindi or English, with internet access, and willing to provide electronic consent.
Exclusion Criteria: Individuals with a history of vaccine-related adverse events, those unable to complete the questionnaire, or unwilling to participate.
Data Collection Instrument
A structured, pre-validated bilingual (Hindi and English) questionnaire was developed and hosted on Google Forms. The questionnaire comprised four sections:
Socio-Demographic Information: Age, gender, education, occupation, marital status, and healthcare access.
Knowledge of Adult Vaccination: Awareness of vaccine-preventable diseases, vaccine purposes, and schedules for Hepatitis B, flu, COVID-19 boosters, and HPV.
Attitudes Toward Vaccination: Perceptions of vaccine importance, safety, and efficacy.
Barriers to Vaccination: Logistical, cultural, psychological, and informational obstacles.
The questionnaire was pilot-tested among 30 adults (excluded from final analysis) to ensure clarity, cultural appropriateness, and technical functionality. Adjustments were made based on feedback.
Data Collection Procedure
Participants accessed an information sheet outlining study objectives, confidentiality, and voluntary participation. Informed electronic consent was mandatory before accessing the questionnaire. Google Forms settings prevented duplicate submissions, and no personally identifiable data were collected to ensure anonymity.
Scoring and Categorization
Knowledge-based questions were scored with one point per correct answer. Knowledge levels were categorized as:
Very Good Awareness: ≥80% correct answers
Good Awareness: 60–79% correct answers
Fair Awareness: 40–59% correct answers
Poor Awareness: <40% correct answers
Attitudes and barriers were analyzed separately to identify prevailing perceptions and obstacles.
Data Analysis
Data were exported from Google Forms to Microsoft Excel and analyzed using IBM SPSS Statistics version 27.0. Descriptive statistics (frequencies, percentages, means, standard deviations) summarized participant characteristics, knowledge levels, attitudes, and barriers.
Ethical Considerations
The study adhered to ethical guidelines, ensuring participant autonomy, confidentiality, and voluntary participation per the Declaration of Helsinki.
The results provide a comprehensive overview of the socio-demographic profile, knowledge, attitudes, and barriers related to adult vaccination among 480 participants in Himachal Pradesh. The data highlight moderate awareness levels but significant gaps that underscore the need for targeted educational and access-focused interventions.
This table summarizes the socio-demographic profile of the 480 participants, reflecting a diverse representation of age,gender, education, occupation, marital status, and healthcare access. The majority were young to middle-aged adults, with notable rural representation, emphasizing the study’s focus on rural vaccination challenges (Table 1).
Table 1: socio-demographic characteristics of participants
| Variable | Category | Frequency (n) | Percentage (%) |
| Age Group (Years) | 18–25 | 168 | 35.0 |
| 26–35 | 182 | 37.9 | |
| 36–45 | 96 | 20.0 | |
| 46–65 | 34 | 7.1 | |
| Gender | Female | 264 | 55.0 |
| Male | 216 | 45.0 | |
| Education Level | No formal education | 24 | 5.0 |
| Primary school | 58 | 12.1 | |
| Secondary school | 168 | 35.0 | |
| Undergraduate degree | 163 | 34.0 | |
| Postgraduate degree | 67 | 13.9 | |
| Occupation | Homemaker | 120 | 25.0 |
| Self-employed | 96 | 20.0 | |
| Government employee | 67 | 13.9 | |
| Private sector | 106 | 22.1 | |
| Unemployed | 91 | 19.0 | |
| Marital Status | Single | 192 | 40.0 |
| Married | 250 | 52.1 | |
| Divorced/Widowed | 38 | 7.9 |
This table presents responses to 20 comprehensive questions assessing knowledge of Hepatitis B, flu, COVID-19 boosters, and HPV vaccines, attitudes toward their importance, and perceived barriers. The questions were designed to capture a broad understanding of adult vaccination literacy, with correct answers in bold. The results indicate moderate awareness but critical gaps in understanding vaccine schedules and specific disease prevention (Table 2).
Table 2: awareness and attitudes toward adult vaccination
| No. | Question | Options | Correct Responses (n) | Percentage (%) |
| 1 | What does the Hepatitis B vaccine primarily prevent? | a) Lung infection, b) Liver disease, c) Skin infection, d) Heart disease | 360 | 75.0 |
| 2 | Can adult vaccination prevent serious diseases? | a) Yes, b) No, c) Only in children, d) Only in urban areas | 384 | 80.0 |
| 3 | Is fever a common symptom of influenza? | a) Yes, b) No, c) Only in elderly, d) Only in children | 355 | 74.0 |
| 4 | Does the HPV vaccine reduce cervical cancer risk in adults? | a) Yes, b) No, c) Only in teenagers, d) Only in urban areas | 326 | 67.9 |
| 5 | Are COVID-19 boosters recommended for adults? | a) Yes, b) No, c) Only for elderly, d) Only in pandemics | 374 | 77.9 |
| 6 | Can Hepatitis B be asymptomatic in early stages? | a) Yes, b) No, c) Only in men, d) Only with symptoms | 307 | 64.0 |
| 7 | What is the purpose of the flu vaccine? | a) Treat allergies, b) Prevent influenza, c) Cure colds, d) Boost immunity generally | 345 | 71.9 |
| 8 | How often should adults get the flu vaccine? | a) Every 5 years, b) Annually, c) Only if symptomatic, d) Never | 288 | 60.0 |
| 9 | Does unvaccinated status increase Hepatitis B transmission risk? | a) Yes, b) No, c) Only in rural areas, d) Only in youth | 360 | 75.0 |
| 10 | Are vaccine-preventable diseases always fatal? | a) Yes, b) No, c) Only in late stages, d) Only without treatment | 394 | 82.1 |
| 11 | Does smoking increase influenza complications? | a) Yes, b) No, c) Only in elderly, d) Only with heavy smoking | 326 | 67.9 |
| 12 | Can early vaccination improve disease outcomes? | a) Yes, b) No, c) Only with medication, d) Only in urban areas | 403 | 83.9 |
| 13 | Is HPV infection always symptomatic? | a) Yes, b) No, c) Only in women, d) Only with cancer | 302 | 62.9 |
| 14 | Should adults over 30 get Hepatitis B vaccination if unvaccinated? | a) Yes, b) No, c) Only if at risk, d) Only in urban areas | 350 | 72.9 |
| 15 | Can vaccines reduce the severity of COVID-19? | a) Yes, b) No, c) Only in youth, d) Only with boosters | 374 | 77.9 |
| 16 | Does family history increase Hepatitis B risk? | a) Yes, b) No, c) Only for liver cancer, d) Only in urban areas | 317 | 66.0 |
| 17 | Is cost a common barrier to adult vaccination? | a) Yes, b) No, c) Only in rural areas, d) Only for youth | 398 | 82.9 |
| 18 | Which is NOT a benefit of adult vaccination? | a) Disease prevention, b) Reduced severity, c) Community protection, d) Improved eyesight | 345 | 71.9 |
| 19 | Can flu vaccines protect against severe complications? | a) Yes, b) No, c) Only in children, d) Only with medication | 355 | 74.0 |
| 20 | Who should administer adult vaccines? | a) Self, b) Healthcare professional, c) Traditional healer, d) Family member | 384 | 80.0 |
This table categorizes participants’ knowledge levels based on their performance on the 20 knowledge-based questions. The majority demonstrated Good awareness, but a notable proportion with Fair or Poor awareness indicates the need for enhanced vaccination education (Table 3).
Table 3: Knowledge Score Classification
| Knowledge Category | Score Range | Frequency (n) | Percentage (%) |
| Very Good | ≥80% | 134 | 27.9 |
| Good | 60%–79% | 221 | 46.0 |
| Fair | 40%–59% | 96 | 20.0 |
| Poor | <40% | 29 | 6.1 |
This study provides critical insights into the awareness, attitudes, and barriers surrounding adult vaccination in Himachal Pradesh, a region where rurality, socio-cultural norms, and limited healthcare infrastructure significantly influence public health outcomes. The findings reveal a moderately encouraging level of vaccination literacy, with 80.0% of participants recognizing that adult vaccines prevent serious diseases and 82.1% correctly identifying that vaccine-preventable diseases are not always fatal. High awareness of specific vaccine purposes, such as Hepatitis B preventing liver disease (75.0%), flu vaccines preventing influenza (71.9%), and COVID-19 boosters reducing disease severity (77.9%), suggests that recent public health campaigns, possibly amplified by the COVID-19 pandemic, have had some impact in rural and semi-urban communities. The strong recognition of cost as a barrier (82.9%) and healthcare professionals as vaccine administrators (80.0%) further indicates a baseline understanding of vaccination logistics, reflecting the gradual penetration of health education in Himachal Pradesh.
Despite these positive trends, significant knowledge gaps and attitudinal barriers persist, highlighting the challenges of promoting adult vaccination in a region with low health literacy and systemic constraints. Only 60.0% of participants correctly identified the annual frequency for flu vaccination, and awareness of the asymptomatic nature of Hepatitis B (64.0%) and HPV infections (62.9%) was suboptimal. These gaps are particularly concerning, as they may lead to delayed or missed vaccinations, increasing the risk of preventable diseases like liver cancer (from Hepatitis B) and cervical cancer (from HPV). The moderate awareness of HPV vaccination’s role in reducing cervical cancer risk among adults (67.9%) aligns with findings from the cervical cancer study, which noted similar deficiencies in HPV knowledge (68.3%), suggesting a broader regional challenge in understanding vaccines beyond childhood schedules. Misconceptions, such as the belief that family history increases Hepatitis B risk (only 66.0% correct), further underscore the need for targeted education to dispel myths and clarify disease-specific risks.
The socio-demographic profile, with 72.9% of participants aged 18–35 and 32.1% reporting limited healthcare access, underscores both opportunities and challenges for adult vaccination programs. The younger cohort, likely more receptive to health messaging via digital platforms, represents an ideal target for awareness campaigns. However, the significant proportion with limited healthcare access highlights systemic barriers, including geographic isolation in Himachal Pradesh’s hilly terrain and financial constraints, which align with the high recognition of cost as a barrier (82.9%). These findings are consistent with national trends in India, where adult vaccination coverage for Hepatitis B and flu remains low due to accessibility issues and a lack of routine adult immunization programs. The moderate awareness of behavioral risk factors, such as smoking increasing influenza complications (67.9%), suggests that public health messaging must better integrate lifestyle-related education to enhance vaccine uptake.
The knowledge score classification reveals a divide in vaccination literacy: while 46.0% demonstrated "Good" awareness and 27.9% achieved "Very Good" awareness, a concerning 26.1% fell into the "Fair" or "Poor" categories. This subgroup is at risk of under-vaccination, perpetuating the burden of vaccine-preventable diseases in Himachal Pradesh. The online survey methodology, while effective in reaching a diverse sample, may have favored more educated and digitally connected individuals, potentially underrepresenting rural populations with lower literacy or no internet access, a limitation also noted in the mental health study. Social desirability bias may have influenced responses, particularly on sensitive topics like vaccine safety perceptions, leading to an overestimation of awareness. These limitations suggest caution in generalizing the findings to the entire population of Himachal Pradesh.
The implications of these findings are significant for public health policy in Himachal Pradesh. The moderate awareness levels indicate that existing vaccination campaigns have laid a foundation, but they must be intensified and tailored to address specific gaps, such as vaccine schedules and asymptomatic disease risks. Community-based interventions, leveraging local health workers and Gram Panchayats, could enhance outreach in rural areas, while subsidized or free vaccination programs could mitigate cost barriers. Integrating adult vaccines into primary healthcare, as advocated by India’s Universal Immunization Programme, is critical to improving access for the 32.1% with limited healthcare access. Digital platforms, given the engagement of younger participants, offer a promising avenue for education, though efforts must ensure inclusivity for those without internet access [8,9]. Future research should explore longitudinal trends in adult vaccination uptake and evaluate the impact of targeted interventions in reducing knowledge gaps and increasing coverage in rural Himachal Pradesh.
This study illuminates the complex landscape of adult vaccination awareness in Himachal Pradesh, revealing moderate knowledge of Hepatitis B, flu, COVID-19 boosters, and HPV vaccines alongside persistent gaps and barriers that hinder uptake, particularly in rural communities. While encouraging awareness of vaccine purposes and disease prevention exists, deficiencies in understanding vaccine schedules, asymptomatic infections, and specific disease risks, coupled with cost and access barriers, underscore the urgent need for comprehensive interventions. To enhance adult immunization coverage, multi-faceted strategies are essential, including targeted educational campaigns, integration of vaccines into primary care, subsidized vaccination programs, and community-based outreach to address myths and improve access, ensuring that adult vaccination becomes a cornerstone of health protection for all in Himachal Pradesh.
Kanugula, S., et al. "Vaccination Awareness in Adult Patients at a Tertiary Care Hospital." Journal of Medical Science and Research, vol. 12, no. 3, 2024, pp. 207–212.
RG Hospital Ludhiana. "Adult Immunization: Vaccinations Aren't Just for Kids." RG Hospital Ludhiana,
https://rghospitalludhiana.com/blog/adult-immunization-vaccinations-arent-just-for-kids/. Accessed 1 Feb. 2025.
Times of India. "Why Adult Immunisation Is Important." Times of India, https://timesofindia.indiatimes. com/life-style/health-fitness/health-news/why-adult-immunisation-is-important/articleshow/113171795.cms. Accessed 1 Feb. 2025.
Dash R., et al. "Towards Adult Vaccination in India: A Narrative Literature Review." Human Vaccines & Immunotherapeutics, vol. 16, no. 4, 2020, pp. 991–1001.
Mint. "Vaccination Isn’t Just for Babies." Livemint, https://www.livemint.com/news/business-of-life/vaccination-isn-t-just-for-babies-1541317964826.html. Accessed 1 Feb. 2025.
Apollo Clinic. "Vaccination Is Not Only for Kids: There Are Adult Vaccines Too." Apollo Clinic, https://www.apolloclinic.com/blog/vaccination-is-not-only-for-kids-there-are-adult-vaccines-too. Accessed 12 Feb. 2025.
Sakra World Hospital. "What Is Adult Vaccination?" Sakra World Hospital, https://www.sakraworldhospital. com/blogs/what-is-adult-vaccination/332. Accessed 13 Feb. 2025.
Emvac. Adult Vaccination Booklet. https://www .emvac.in/wp-content/uploads/2024/06/ Adult-Vaccination-Booklet.pdf. Accessed 17 Feb. 2025.
Lahariya C., and Bhardwaj P. "Adult Vaccination in India: Status and the Way Forward." Human Vaccines & Immunotherapeutics, vol. 16, no. 7, 2020, pp. 1508–1510.
Download PDF
Download PDF
Download PDF
Download PDF
Download XML
