Vaccination is one of the most effective public health interventions, traditionally associated with childhood immunization programs that have dramatically reduced the burden of infectious diseases worldwide. However, the importance of adult vaccination—critical for the prevention of vaccine-preventable diseases such as Hepatitis B, influenza, Human Papillomavirus (HPV)-related cancers, and COVID-19—is often overlooked. Despite the availability of safe and effective vaccines, adult immunization coverage remains suboptimal in many parts of the world, including India, due to low public awareness, vaccine hesitancy, misconceptions about vaccine safety, and gaps in healthcare provider recommendations [1-4].

In the Indian context, adult vaccination has historically received less emphasis compared to pediatric immunization initiatives. National health strategies have primarily focused on childhood programs like the Universal  Immunization  Programme  (UIP),   with    adult vaccination guidelines emerging relatively recently, particularly in response to the COVID-19 pandemic. Nonetheless, uptake of vaccines such as the Hepatitis B vaccine, annual influenza shots, COVID-19 booster doses, and the HPV vaccine for cancer prevention remains inconsistent across populations. Sociocultural factors, misinformation, financial barriers, and a pervasive sense of "invincibility" among younger and middle-aged adults contribute to the neglect of routine adult immunizations. Strengthening adult vaccine coverage is vital not only for individual protection but also for building community-level herd immunity and mitigating the broader health system burden associated with preventable infectious diseases [5-8].

The Solan district of Himachal Pradesh, characterized by its predominantly rural and semi-urban population, evolving healthcare access, and traditional health beliefs, presents a unique landscape to explore community knowledge and attitudes towards adult vaccination. Despite recent public health efforts, particularly during the COVID-19 pandemic, adult vaccine literacy remains uneven, and comprehensive data on vaccine awareness, acceptance, and barriers within this community are scarce. Understanding these dynamics is crucial for developing targeted educational interventions and policy frameworks to bridge the knowledge-action gap in adult immunization practices.

This study aims to assess the level of awareness, attitudes, and perceptions related to adult vaccines—specifically Hepatitis B, influenza, COVID-19 boosters, and HPV—among adults in Solan district. By identifying prevailing misconceptions, sources of vaccine information, and determinants of vaccine acceptance or hesitancy, the findings seek to inform the design of culturally sensitive public health campaigns and healthcare strategies to enhance adult vaccination uptake, thereby strengthening infectious disease prevention across the district.

Study Design

This study adopted a descriptive, cross-sectional survey design to evaluate the level of awareness, attitudes, and perceptions regarding adult vaccination among the adult population of Solan district, Himachal Pradesh. The cross-sectional approach enabled the collection of real-time data on knowledge, acceptance, and barriers toward adult vaccines such as Hepatitis B, influenza, COVID-19 boosters, and HPV vaccines.

Study Area and Population

The research was conducted across various rural, semi-urban, and emerging urban areas within Solan district, ensuring socio-demographic diversity. The target population comprised adults aged 18 years and above, irrespective of previous vaccination status or history of vaccine-preventable diseases. To maintain focus on community perceptions, practicing healthcare professionals and medical students were excluded from participation.

Study Duration

Data collection was carried out over a three-month period, from January to March 2025, allowing for extensive outreach and comprehensive participant inclusion across different parts of the district.

Sample Size and Sampling Technique

A minimum sample size of 400 participants was calculated, considering a 95% confidence level, a 5% margin of error, and an anticipated 50% prevalence of vaccine awareness in the absence of prior localized data. Purposive and snowball sampling techniques were utilized. Initial participants were recruited through online community forums, local WhatsApp and Facebook groups, and village WhatsApp committees. Participants were encouraged to circulate the survey within their social networks to maximize reach across varied socio-economic and educational backgrounds.

Inclusion and Exclusion Criteria

Inclusion Criteria:

• Adults aged 18 years and above residing in Solan district

• Ability to understand and respond to the survey in Hindi or English

• Access to a smartphone, tablet, or computer with internet connectivity

• Willingness to provide informed consent before participating

Exclusion Criteria:

• Practicing healthcare professionals (doctors, nurses, pharmacists, and health counselors).

• Medical and allied health students.

• Incomplete or partially filled survey responses.

Data Collection Tool

A structured, pre-validated bilingual (Hindi and English) questionnaire was developed in consultation with public health experts, epidemiologists, and immunologists. Hosted on Google Forms, the questionnaire was mobile-friendly and designed for easy accessibility. It comprised four key sections:

• Demographic Details: Age, gender, education level, occupation, and residential setting.

• Awareness Assessment: Knowledge regarding Hepatitis B, influenza, COVID-19 booster, and HPV vaccines, recommended schedules, and benefits.

• Attitudes and Perceptions: Beliefs about vaccine safety, effectiveness, necessity, and perceived barriers to adult vaccination.

• Vaccination Status and Information Sources: Self-reported history of adult vaccinations and sources of vaccine-related information (e.g., healthcare providers, media, social networks).

Data Collection Procedure

Participants accessed the survey link, which was accompanied by a brief description of the study objectives, assurances of confidentiality, and an informed consent statement. Participation was voluntary, and respondents could withdraw at any stage without providing justification. Only fully completed surveys were considered for final analysis.

Scoring and Data Classification

Knowledge questions were scored as follows: one point for each correct response and zero for incorrect or "don't know" answers. Based on cumulative scores, knowledge levels were categorized into four groups:

• Very Good Knowledge (≥80% correct responses)

• Good Knowledge (60%–79% correct responses)

• Fair Knowledge (41%–59% correct responses)

• Poor Knowledge (<40% correct responses)

Attitudes toward vaccination were analyzed using Likert-scale items and thematic categorization, while vaccination status and information sources were descriptively summarized.

Data Analysis

Data were exported from Google Forms into Microsoft Excel for cleaning and coding and subsequently analyzed using SPSS version 26.0. Descriptive statistics, including frequencies, percentages, means, and standard deviations, were used to summarize the demographic characteristics, awareness levels, and attitudes. 

Ethical Considerations

Online informed consent was obtained from all participants before survey participation. Anonymity and confidentiality of responses were strictly maintained, and no personally identifiable information was collected. The study adhered to ethical standards for research involving human participants as per the Declaration of Helsinki.

Table 1 illustrates the socio-demographic distribution of the 400 participants surveyed from Solan district. The majority (38.5%) belonged to the 26–35 years age group, followed by 25.3% aged 36–45 years, and 24.3% aged 18–25 years, indicating a predominantly young and middle-aged adult population—an important demographic for adult vaccination initiatives. Females represented a slightly higher proportion (52.3%) compared to males (47.8%). In terms of education, 36.3% had completed secondary schooling and 29.3% held undergraduate degrees, although 7.5% had no formal education, highlighting the need for accessible and literacy-sensitive vaccination awareness programs. Occupation-wise, homemakers formed the largest group (35.3%), followed by self-employed individuals (21.3%), and students/unemployed participants (21.3%). Reflecting Solan’s demographic composition, a significant majority (65.3%) resided in rural areas, while 34.8% were from urban settings, underscoring the need for targeted vaccination strategies that address rural health literacy gaps.

Table 2 presents participants' awareness and knowledge levels regarding adult vaccination. Encouragingly, 79.5% correctly identified the primary purpose of adult vaccines as preventing infectious diseases, while 74.0% recognized that the Hepatitis B vaccine can prevent liver cancer. Awareness of the necessity for annual influenza vaccination stood at 62.3%, and 65.3% knew that the HPV vaccine helps prevent cervical cancer. Knowledge about COVID-19 boosters was relatively strong (75.8%), and a notable 78.5% understood that adult vaccines could reduce hospitalization rates. However, only 59.3% were aware that adult vaccines are partially covered by government programs, and misconceptions about vaccine safety, strain coverage, and eligibility persisted among 20%–35% of respondents across various questions. Notably, 81.5% agreed on the importance of consulting doctors before vaccination, and 79.8% acknowledged the role of misinformation in hindering vaccine uptake. Overall, while foundational awareness about adult vaccination was reasonably high, several critical knowledge gaps were identified, particularly regarding vaccine schedules, safety, and health policy coverage.

Table 3 categorizes participants based on their cumulative knowledge scores related to adult vaccination. About 29.8% of respondents achieved a "Very Good" knowledge score (≥80% correct answers), reflecting strong awareness among nearly one-third of the sample. The largest segment, 43.5%, fell into the "Good" category (60%–79%), indicating a reasonably well-informed but still improvable understanding. Meanwhile, 19.8% were classified as having "Fair" knowledge (41%–59%), and 7.0% exhibited "Poor" knowledge (<40%), signaling that roughly one-quarter of the population possesses insufficient information about adult vaccines. These findings underscore the need for targeted, community-driven educational campaigns that address persistent misconceptions and promote a deeper understanding of the importance of adult immunization in disease prevention.

Table 1: Socio-Demographic Characteristics of Participants

Table 2: Awareness and Knowledge of Adult Vaccination Among Participants

Table 3: Knowledge Score Classification

This study provides valuable insights into the awareness, knowledge, and attitudes toward adult vaccination among the population of Solan district, Himachal Pradesh. The findings reveal a cautiously optimistic landscape, with a substantial proportion of participants demonstrating a foundational understanding of the importance of adult vaccines, yet critical gaps in comprehensive vaccine literacy, misconceptions about vaccine safety, and inconsistent knowledge about vaccination schedules persist—challenges that could undermine efforts to strengthen adult immunization coverage.

The socio-demographic distribution of the participants (Table 1) reflects a representative sample of Solan’s evolving population, with a dominance of young and middle-aged adults (38.5% aged 26–35 years and 25.3% aged 36–45 years), who are essential targets for adult vaccination initiatives. The slightly higher proportion of female participants (52.3%) is particularly notable given that women often influence family health decisions and vaccine acceptance within households. Education levels varied considerably, with 36.3% completing secondary schooling and 29.3% holding undergraduate degrees, although 7.5% lacked formal education, highlighting the need for tailored messaging that is accessible across varying literacy levels. Importantly, the predominantly rural setting (65.3%) underscores the necessity of rural-centric interventions, considering the documented disparities in vaccine access, health literacy, and healthcare-seeking behavior between rural and urban populations in India.

The assessment of vaccine awareness and knowledge (Table 2) revealed promising trends but also areas of concern. Encouragingly, a majority of participants (79.5%) understood the preventive role of adult vaccines, and substantial proportions correctly identified the benefits of Hepatitis B, influenza, COVID-19 booster, and HPV vaccinations. Particularly notable is the high awareness of COVID-19 booster importance (75.8%), reflecting the intense national and global focus during the pandemic. However, knowledge regarding annual influenza vaccination (62.3%) and HPV vaccine eligibility (61.5%) was comparatively lower, indicating a lack of understanding about vaccines beyond COVID-19. Misconceptions were also apparent: 35%–40% of participants held incorrect or incomplete beliefs regarding vaccine safety, necessity for booster doses, and government coverage of adult vaccines. Although a strong majority (81.5%) agreed on the importance of consulting healthcare providers before vaccination, the relatively low awareness (59.3%) of government programs supporting adult vaccination points to informational gaps about financial support mechanisms—a critical factor influencing vaccine uptake in lower-income communities.

The knowledge score classification (Table 3) further contextualizes these findings. While a combined 73.3% of participants exhibited "Good" to "Very Good" knowledge levels, a significant 26.8% fell into the "Fair" or "Poor" categories. This segment of the population, nearly one in four adults, remains vulnerable to misinformation, vaccine hesitancy, and low immunization uptake—threatening efforts to achieve comprehensive community immunity against vaccine-preventable diseases. Comparisons with similar studies in other Indian states and rural districts reveal parallel challenges: while awareness regarding COVID-19 vaccination surged post-pandemic, broader adult vaccination literacy remains limited, hampered by entrenched cultural beliefs, misinformation, and a lack of routine adult immunization campaigns comparable to childhood immunization drives.

Socio-cultural influences in Solan, like in many parts of rural India, play a pivotal role in shaping vaccine perceptions. Traditional reliance on natural remedies, a general underestimation of adult disease risks, and the misconception that vaccines are primarily for children create barriers to adult vaccine acceptance. Furthermore, the increasing spread of misinformation through social media platforms exacerbates vaccine hesitancy, as acknowledged by 79.8% of participants. These dynamics underscore the pressing need for culturally sensitive, grassroots public health education strategies that leverage trusted community leaders, local healthcare workers, and religious institutions to normalize adult vaccination as a routine preventive practice.

From a policy and public health perspective, several strategic priorities emerge. First, educational initiatives must expand beyond COVID-19 to include other critical vaccines such as Hepatitis B, influenza, and HPV, emphasizing their role in preventing long-term health complications like liver cancer, respiratory diseases, and cervical cancer. Second, targeted outreach programs are needed to bridge knowledge gaps among rural residents, individuals with low literacy, and those categorized under "Fair" and "Poor" knowledge groups. Third, healthcare providers must be equipped and encouraged to proactively recommend adult vaccinations during routine consultations, particularly in primary health centers and community health outreach settings. In parallel, systematic efforts must address misinformation through robust media engagement, community workshops, and digital literacy programs that equip individuals to critically assess vaccine-related information.^6-9

Additionally, policy interventions such as subsidizing adult vaccines, integrating adult vaccination services into existing health infrastructure (e.g., during outpatient visits or health camps), and launching state-wide adult immunization campaigns modeled after successful childhood initiatives could dramatically improve uptake. Considering the significant role financial considerations play in vaccine hesitancy, expanding public awareness about government-supported vaccination programs is critical for ensuring equitable access.

Overall, while the current findings reflect positive momentum in vaccine awareness post-pandemic, the study highlights that adult vaccination literacy in Solan district is still evolving. Concerted, multi-level efforts—combining education, policy, healthcare provider engagement, and community mobilization—will be essential to close the awareness-practice gap and ensure that adult vaccination becomes a normalized, routine part of preventive healthcare in the district.

This study sheds light on the current state of public awareness, knowledge, and attitudes towards adult vaccination in Solan district, revealing a promising but incomplete understanding among the adult population. While a substantial proportion demonstrated good to very good awareness regarding the role of vaccines in preventing infectious diseases like Hepatitis B, influenza, COVID-19, and HPV-related conditions, critical knowledge gaps, lingering misconceptions, and limited awareness about government vaccination programs persist. These findings underscore the urgent need for targeted, culturally sensitive health education initiatives, robust community engagement, and healthcare system strengthening to normalize adult vaccination as a routine preventive measure. Addressing socio-cultural barriers, countering misinformation, improving healthcare provider engagement, and expanding public awareness about vaccine safety, necessity, and accessibility will be key to closing the knowledge-action gap. A coordinated, multi-sectoral approach that empowers individuals, supports healthcare infrastructure, and fosters community trust is essential to enhance adult vaccine uptake, thereby safeguarding public health and reducing the burden of vaccine-preventable diseases in Solan district.

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