const {
  Document, Packer, Paragraph, TextRun, Table, TableRow, TableCell,
  HeadingLevel, AlignmentType, LevelFormat, WidthType, BorderStyle,
  VerticalAlign, PageNumber, Header, Footer, ShadingType
} = require('docx');
const fs = require('fs');

// ── helpers ──────────────────────────────────────────────────────────────────
const h1 = (text) => new Paragraph({
  heading: HeadingLevel.HEADING_1,
  children: [new TextRun({ text, bold: true, size: 28, font: "Arial" })]
});

const h2 = (text) => new Paragraph({
  heading: HeadingLevel.HEADING_2,
  children: [new TextRun({ text, bold: true, size: 24, font: "Arial" })]
});

const body = (text, opts = {}) => new Paragraph({
  spacing: { before: 80, after: 80, line: 360 },
  children: [new TextRun({ text, font: "Arial", size: 22, ...opts })]
});

const bold = (text) => new Paragraph({
  spacing: { before: 80, after: 80 },
  children: [new TextRun({ text, bold: true, font: "Arial", size: 22 })]
});

const bullet = (text) => new Paragraph({
  numbering: { reference: "bullets", level: 0 },
  spacing: { before: 40, after: 40 },
  children: [new TextRun({ text, font: "Arial", size: 22 })]
});

const numbered = (text) => new Paragraph({
  numbering: { reference: "numbers", level: 0 },
  spacing: { before: 40, after: 40 },
  children: [new TextRun({ text, font: "Arial", size: 22 })]
});

const space = () => new Paragraph({ children: [new TextRun("")], spacing: { before: 60, after: 60 } });

const divider = () => new Paragraph({
  border: { bottom: { style: BorderStyle.SINGLE, size: 6, color: "999999" } },
  children: [new TextRun("")]
});

// simple table helper: rows = [["cell","cell"], ...]
const makeTable = (rows, headerRow = true) => {
  const tRows = rows.map((cells, ri) =>
    new TableRow({
      tableHeader: ri === 0 && headerRow,
      children: cells.map((txt, ci) =>
        new TableCell({
          shading: ri === 0 && headerRow ? { fill: "2E74B5", type: ShadingType.CLEAR, color: "FFFFFF" } : (ri % 2 === 0 ? { fill: "EBF3FB", type: ShadingType.CLEAR } : {}),
          verticalAlign: VerticalAlign.CENTER,
          margins: { top: 80, bottom: 80, left: 100, right: 100 },
          children: [new Paragraph({
            children: [new TextRun({
              text: txt,
              font: "Arial",
              size: 20,
              bold: ri === 0 && headerRow,
              color: ri === 0 && headerRow ? "FFFFFF" : "000000"
            })]
          })]
        })
      )
    })
  );
  return new Table({
    width: { size: 100, type: WidthType.PERCENTAGE },
    rows: tRows
  });
};

// ── document ─────────────────────────────────────────────────────────────────
const doc = new Document({
  numbering: {
    config: [
      {
        reference: "bullets",
        levels: [{
          level: 0, format: LevelFormat.BULLET, text: "\u2022",
          alignment: AlignmentType.LEFT,
          style: { paragraph: { indent: { left: 720, hanging: 360 } } }
        }]
      },
      {
        reference: "numbers",
        levels: [{
          level: 0, format: LevelFormat.DECIMAL, text: "%1.",
          alignment: AlignmentType.LEFT,
          style: { paragraph: { indent: { left: 720, hanging: 360 } } }
        }]
      }
    ]
  },
  styles: {
    default: {
      document: { run: { font: "Arial", size: 22 } }
    },
    paragraphStyles: [
      {
        id: "Heading1", name: "Heading 1", basedOn: "Normal", next: "Normal", quickFormat: true,
        run: { size: 32, bold: true, font: "Arial", color: "1F3864" },
        paragraph: { spacing: { before: 300, after: 120 }, outlineLevel: 0 }
      },
      {
        id: "Heading2", name: "Heading 2", basedOn: "Normal", next: "Normal", quickFormat: true,
        run: { size: 26, bold: true, font: "Arial", color: "2E74B5" },
        paragraph: { spacing: { before: 200, after: 100 }, outlineLevel: 1 }
      }
    ]
  },
  sections: [{
    properties: {
      page: {
        margin: { top: 1080, bottom: 1080, left: 1080, right: 1080 }
      }
    },
    headers: {
      default: new Header({
        children: [new Paragraph({
          alignment: AlignmentType.RIGHT,
          children: [new TextRun({ text: "HPV Vaccination KAP Study Protocol | Anand, Gujarat", font: "Arial", size: 18, color: "888888" })]
        })]
      })
    },
    footers: {
      default: new Footer({
        children: [new Paragraph({
          alignment: AlignmentType.CENTER,
          children: [
            new TextRun({ text: "Page ", font: "Arial", size: 18, color: "888888" }),
            new TextRun({ children: [PageNumber.CURRENT], font: "Arial", size: 18, color: "888888" }),
            new TextRun({ text: " of ", font: "Arial", size: 18, color: "888888" }),
            new TextRun({ children: [PageNumber.TOTAL_PAGES], font: "Arial", size: 18, color: "888888" })
          ]
        })]
      })
    },
    children: [

      // ── TITLE PAGE ──────────────────────────────────────────────────────────
      new Paragraph({
        alignment: AlignmentType.CENTER,
        spacing: { before: 600, after: 200 },
        children: [new TextRun({ text: "RESEARCH PROTOCOL", font: "Arial", size: 36, bold: true, color: "1F3864" })]
      }),
      new Paragraph({
        alignment: AlignmentType.CENTER,
        spacing: { before: 100, after: 400 },
        children: [new TextRun({ text: "________________________________________", font: "Arial", size: 24, color: "2E74B5" })]
      }),
      new Paragraph({
        alignment: AlignmentType.CENTER,
        spacing: { before: 100, after: 300 },
        children: [new TextRun({
          text: "Community-Based Assessment of Knowledge, Attitudes, Perceived Barriers, and Acceptance of Human Papillomavirus (HPV) Vaccination: Tool Validation and Health Education Resource Development",
          font: "Arial", size: 28, bold: true, color: "1F3864"
        })]
      }),
      new Paragraph({
        alignment: AlignmentType.CENTER,
        spacing: { before: 300, after: 100 },
        children: [new TextRun({ text: "Principal Investigator: [Student Name], Pharm.D 5th Year", font: "Arial", size: 22 })]
      }),
      new Paragraph({
        alignment: AlignmentType.CENTER,
        spacing: { before: 80, after: 80 },
        children: [new TextRun({ text: "Guide: [Faculty Name], Department of Pharmacy Practice", font: "Arial", size: 22 })]
      }),
      new Paragraph({
        alignment: AlignmentType.CENTER,
        spacing: { before: 80, after: 80 },
        children: [new TextRun({ text: "Institution: [College Name], Anand, Gujarat", font: "Arial", size: 22 })]
      }),
      new Paragraph({
        alignment: AlignmentType.CENTER,
        spacing: { before: 80, after: 80 },
        children: [new TextRun({ text: "Duration: [Start Month, Year] to [End Month, Year] (6 months)", font: "Arial", size: 22 })]
      }),
      new Paragraph({
        alignment: AlignmentType.CENTER,
        spacing: { before: 80, after: 80 },
        children: [new TextRun({ text: "Submitted to: Institutional Ethics Committee", font: "Arial", size: 22, italics: true })]
      }),

      divider(), space(),

      // ── 1. INTRODUCTION ─────────────────────────────────────────────────────
      h1("1. Introduction"),
      body("Human Papillomavirus (HPV) is a double-stranded DNA virus with over 200 known genotypes, of which high-risk types 16 and 18 are responsible for approximately 70% of all cervical cancers globally.1 HPV infection is the most common sexually transmitted infection worldwide, and persistent infection with oncogenic HPV types is the primary causative factor in the development of cervical cancer.2 As of 2024, cervical cancer accounts for an estimated 604,000 new cases and 280,000 deaths annually, with the highest burden in low- and middle-income countries.3"),
      space(),
      body("Safe and effective prophylactic vaccines are available, including the bivalent (Cervarix), quadrivalent (Gardasil), nonavalent (Gardasil-9), and India's indigenous quadrivalent vaccine Cervavac (Serum Institute of India), all targeting HPV types 16 and 18.4 Systematic reviews confirm that vaccination significantly reduces HPV infection, precancerous lesions, and invasive cervical cancer, with greatest effectiveness when administered to girls aged 9 to 14 years before exposure.5 Despite this, community-level vaccine acceptance in India remains low due to insufficient awareness, cultural barriers, and widespread misinformation, necessitating urgent community-based research and targeted health education."),

      space(), divider(), space(),

      // ── 2. REVIEW OF LITERATURE ─────────────────────────────────────────────
      h1("2. Review of Literature"),
      body("Studies from India consistently reveal poor HPV vaccination awareness across all population groups. Aggarwal et al. (2025) found significant knowledge gaps regarding vaccine schedules and target age groups even among healthcare providers at a Delhi tertiary centre.6 Kavyarani et al. (2025) reported that less than half of medical professionals could correctly identify HPV vaccine target groups.7 Gandhi et al. (2024) conducted a KAP study among rural women in Gujarat - geographically proximate to the present study site - and found low awareness of HPV infection and the existence of a preventive vaccine.8"),
      space(),
      body("Ganeshkumar et al. (2025) identified low education, rural residence, and lack of health education as the strongest predictors of poor HPV vaccine knowledge and acceptance in India.9 Vasudevan et al. (2026) reported that knowledge, attitudes, and acceptance of HPV vaccination among marginalized Indian communities varied significantly by caste, education, and geographic setting, with safety concerns and cultural taboos being the most commonly cited barriers.10 Mullassery and Posmontier (2024) highlighted that traditional health beliefs and cultural taboos significantly reduce parental willingness to vaccinate.11"),
      space(),
      body("Collectively, the literature identifies a critical lack of community-level, post-rollout KAP data from Gujarat, absence of validated regional-language tools, and shortage of locally appropriate health education materials - all of which the present study aims to address."),

      space(), divider(), space(),

      // ── 3. NEED OF THE STUDY ────────────────────────────────────────────────
      h1("3. Need of the Study"),
      body("India accounts for approximately 25% of global cervical cancer deaths, with one woman dying every eight minutes from the disease.12 Despite the national HPV vaccination program launched in November 2024 for girls aged 9-14 years using Cervavac, early coverage has been alarmingly low, driven by misinformation, cultural misconceptions, and poor community awareness. Cervical cancer screening coverage in India remains at just 2% as per NFHS-5.13"),
      space(),
      body("Most existing KAP studies are hospital-based, use non-validated tools, and have not been conducted in semi-urban Gujarat. No published community-level data exists from Anand, Gujarat post the 2024 national rollout. A validated, Gujarati-language assessment tool and locally relevant health education resource are urgently needed to generate reliable data and support improved vaccine uptake in this region."),

      space(), divider(), space(),

      // ── 4. RATIONALE ────────────────────────────────────────────────────────
      h1("4. Rationale of the Study"),
      body("Anand, Gujarat lacks community-specific data on HPV vaccination KAP following India's 2024 national rollout. Existing studies rely on non-validated questionnaires with no linguistic or cultural adaptation for the Gujarati population. This study will generate local evidence, produce a validated bilingual (English/Gujarati) KAP tool reusable by future researchers, and create health education resources directly applicable to ongoing national vaccination efforts. Pharmacy students, as accessible community health promoters, are well positioned to conduct this assessment and bridge the gap between policy and community acceptance."),

      space(), divider(), space(),

      // ── 5. OBJECTIVES ───────────────────────────────────────────────────────
      h1("5. Objectives"),
      h2("5.1 Primary Objectives"),
      numbered("To assess the knowledge, attitudes, perceived barriers, and acceptance of HPV vaccination among college students and parents in Anand, Gujarat."),
      numbered("To develop and validate two separate KAP questionnaires - one for college students and one for parents of girls aged 9-18 years - in English and Gujarati."),
      space(),
      h2("5.2 Secondary Objectives"),
      numbered("To identify sociodemographic factors associated with HPV vaccination knowledge and acceptance in each study arm."),
      numbered("To compare knowledge, attitudes, perceived barriers, and acceptance between college students and parents."),
      numbered("To develop a culturally appropriate health education resource (bilingual leaflet/poster) on HPV vaccination for community use."),
      numbered("To assess the acceptability of the developed health education resource among community members."),

      space(), divider(), space(),

      // ── 6. METHODOLOGY ──────────────────────────────────────────────────────
      h1("6. Methodology"),

      h2("6.1 Study Design"),
      body("Cross-sectional, community-based observational study with an embedded tool validation component."),

      space(), h2("6.2 Study Setting"),
      body("Residential areas, colleges, community health centres, PHCs, and Anganwadi centres in Anand district, Gujarat."),

      space(), h2("6.3 Study Duration"),
      body("6 months - including tool development and validation, data collection, analysis, and health education resource development."),

      space(), h2("6.4 Study Population - Two Arms"),
      makeTable([
        ["", "Arm 1: College Students", "Arm 2: Parents"],
        ["Who", "Students enrolled in colleges in Anand", "Parents of girls aged 9-18 years in Anand"],
        ["Age", "18-25 years", "25-55 years (approximately)"],
        ["Rationale", "Near target age group; personal acceptance", "Primary decision-makers for daughter's vaccination"],
        ["Recruitment site", "College campuses", "PHCs, Anganwadis, residential areas"]
      ]),

      space(), h2("6.5 Sample Size"),
      body("Formula: n = Z2 x p x (1-p) / d2"),
      body("Z = 1.96 (95% CI); p = 0.50 (conservative estimate); d = 0.07 (margin of error)"),
      body("n = (1.96)2 x 0.5 x 0.5 / (0.07)2 = ~196 per arm"),
      body("Adding 10% non-response: ~216 per arm"),
      bold("Total sample = ~432 participants (216 students + 216 parents)"),

      space(), h2("6.6 Sampling Method"),
      body("Arm 1 (Students): Convenient sampling from colleges/universities in Anand district."),
      body("Arm 2 (Parents): Purposive sampling from PHCs, Anganwadi centres, and residential areas where parents of young girls are accessible."),

      space(), h2("6.7 Inclusion Criteria"),
      makeTable([
        ["Criterion", "Arm 1: College Students", "Arm 2: Parents"],
        ["Age", "18-25 years", "25 years or above"],
        ["Specific", "Currently enrolled in college in Anand", "Parent of at least one girl aged 9-18 years"],
        ["Residence", "Anand district for ≥6 months", "Anand district for ≥6 months"],
        ["Consent", "Willing to give written informed consent", "Willing to give written informed consent"]
      ]),

      space(), h2("6.8 Exclusion Criteria"),
      bullet("Healthcare professionals (doctors, nurses, pharmacists) - excluded to assess general community knowledge"),
      bullet("Participants with known cognitive impairment"),
      bullet("Individuals who decline to participate or withdraw consent"),

      space(), divider(), space(),

      // ── 7. DATA COLLECTION TOOL ─────────────────────────────────────────────
      h1("7. Data Collection Tool"),

      h2("7.1 Questionnaire Development"),
      body("Two structured questionnaires will be developed de novo - one for college students and one for parents. Both will be prepared in English and translated into Gujarati using standard forward-backward translation methodology. Each questionnaire will consist of five sections:"),
      space(),
      makeTable([
        ["Section", "Content", "Students (items)", "Parents (items)"],
        ["A", "Sociodemographic information", "8 items", "8 items"],
        ["B", "Knowledge of HPV and cervical cancer", "15 items (MCQ/True-False)", "15 items (MCQ/True-False)"],
        ["C", "Attitudes toward HPV vaccination", "10 items (5-pt Likert)", "10 items (5-pt Likert)"],
        ["D", "Perceived barriers to HPV vaccination", "10 items (5-pt Likert)", "10 items (5-pt Likert)"],
        ["E", "Vaccine acceptance", "5 items (personal acceptance)", "5 items (intent to vaccinate daughter)"]
      ]),

      space(), h2("7.2 Tool Validation Steps"),
      makeTable([
        ["Validation Step", "Method", "Acceptable Threshold"],
        ["Content Validity", "Expert panel of 5-7 (physicians, pharmacists, public health experts) - Content Validity Index (CVI)", "CVI ≥ 0.80"],
        ["Face Validity", "Pilot testing on 15 community members for language clarity", "Majority comprehension confirmed"],
        ["Internal Consistency", "Cronbach's alpha for attitude and barrier subscales", "α ≥ 0.70"],
        ["Test-Retest Reliability", "Re-administration to 30 participants after 2 weeks - ICC", "ICC ≥ 0.75"]
      ]),

      space(), divider(), space(),

      // ── 8. HEALTH EDUCATION RESOURCE ────────────────────────────────────────
      h1("8. Health Education Resource Development"),
      body("A bilingual (Gujarati/Hindi) health education leaflet will be developed covering:"),
      bullet("What is HPV and how is it transmitted?"),
      bullet("Link between HPV and cervical cancer"),
      bullet("Who should receive the HPV vaccine and when?"),
      bullet("Government's free national vaccination program details"),
      bullet("Addressing common myths and misconceptions"),
      bullet("Where to get vaccinated in Anand district"),
      space(),
      body("The leaflet will be reviewed by an expert panel for content accuracy and by 20 community members for readability and acceptability. Readability will be assessed using a validated checklist. Acceptability will be rated on a 5-point scale."),

      space(), divider(), space(),

      // ── 9. STATISTICAL ANALYSIS ─────────────────────────────────────────────
      h1("9. Statistical Analysis Plan"),
      body("Data will be entered in Microsoft Excel and analyzed using SPSS v26 or JASP (free)."),
      space(),
      makeTable([
        ["Analysis", "Purpose"],
        ["Descriptive statistics (frequency, mean, SD)", "Summarize sociodemographic data and KAP scores"],
        ["Chi-square test", "Association between sociodemographic variables and KAP"],
        ["Independent t-test / ANOVA", "Compare KAP scores across groups and between two arms"],
        ["Pearson/Spearman correlation", "Correlation between knowledge, attitude, and acceptance scores"],
        ["Binary logistic regression", "Predictors of HPV vaccine acceptance"]
      ]),
      space(),
      body("Knowledge scores will be graded as: Poor (<50%), Moderate (50-74%), Good (≥75%). A p-value of <0.05 will be considered statistically significant."),

      space(), divider(), space(),

      // ── 10. ETHICAL CONSIDERATIONS ──────────────────────────────────────────
      h1("10. Ethical Considerations"),
      numbered("Institutional Ethics Committee (IEC) approval will be obtained prior to study initiation."),
      numbered("Written informed consent will be taken from all participants."),
      numbered("Participation is voluntary; participants may withdraw at any time without penalty."),
      numbered("Anonymity and confidentiality of participant data will be strictly maintained."),
      numbered("No biological samples or interventions will be performed - the study is purely observational."),
      numbered("The study will adhere to ICMR National Ethical Guidelines for Biomedical and Health Research Involving Human Participants (2017)."),

      space(), divider(), space(),

      // ── 11. EXPECTED OUTCOMES ───────────────────────────────────────────────
      h1("11. Expected Outcomes"),
      numbered("Two validated bilingual (English/Gujarati) KAP questionnaires on HPV vaccination - one for students, one for parents."),
      numbered("Community-level data on HPV vaccination KAP from Anand, Gujarat post-2024 national rollout."),
      numbered("Identification of key sociodemographic predictors of vaccine acceptance in both population groups."),
      numbered("A ready-to-distribute, expert-validated bilingual health education leaflet on HPV vaccination."),

      space(), divider(), space(),

      // ── 12. LIMITATIONS ─────────────────────────────────────────────────────
      h1("12. Limitations"),
      bullet("Self-reported data may be subject to social desirability bias."),
      bullet("Cross-sectional design limits causal inference."),
      bullet("Convenience sampling in Arm 1 may limit generalizability."),
      bullet("Study restricted to Anand district; findings may not represent all of Gujarat."),

      space(), divider(), space(),

      // ── 13. REFERENCES ──────────────────────────────────────────────────────
      h1("13. References"),
      body("1. Jensen JE, Becker GL, Jackson JB, Rysavy MB. Human Papillomavirus and Associated Cancers: A Review. Viruses. 2024;16(5):680. PMID: 38793561"),
      body("2. Centers for Disease Control and Prevention. Chapter 11: Human Papillomavirus. In: Pink Book. Atlanta: CDC; 2024."),
      body("3. World Health Organization. Cervical cancer. Geneva: WHO; 2024. Available from: https://www.who.int/news-room/fact-sheets/detail/cervical-cancer"),
      body("4. Serum Institute of India. Cervavac: Vaccine Information. 2024. Available from: https://cervavac.com"),
      body("5. Ellingson MK, Sheikha H, Nyhan K, et al. HPV vaccine effectiveness by age at vaccination: A systematic review. Hum Vaccin Immunother. 2023;19(2):2239085. PMID: 37529935"),
      body("6. Aggarwal I, Mehta D, Yadav P, et al. KAP on HPV Vaccination among Healthcare Providers in North Delhi. Asian Pac J Cancer Prev. 2025;26(2):671. PMID: 40022716"),
      body("7. Kavyarani C, Kannan Karur A, Chaitra C, et al. KAP of Medical Professionals Regarding Cervical Cancer Prevention and HPV Vaccination. Cureus. 2025. PMID: 41063879"),
      body("8. Gandhi R, Patel A, Patel M, et al. Cervical Cancer Prevention Among Rural Women in Gujarat: A Mixed Methods KAP Study. Cureus. 2024. PMID: 39398714"),
      body("9. Ganeshkumar P, Tank J, Choudhury SS, et al. KAP Study on Cervical Cancer Prevention and HPV Vaccination. South Asian J Cancer. 2025. PMID: 41445902"),
      body("10. Vasudevan U, Kelly-Hanku A, Limbu P, et al. Marginalized voices on HPV vaccination in India. Front Glob Womens Health. 2026. PMID: 42100579"),
      body("11. Mullassery D, Posmontier B. Health beliefs and acculturation on HPV vaccination acceptance among Asian Indian parents. J Am Assoc Nurse Pract. 2024. PMID: 39264332"),
      body("12. Gavi. India, home to 25% of world's cervical cancer deaths, launches nationwide HPV vaccination. 2025. Available from: https://www.gavi.org/vaccineswork/"),
      body("13. National Family Health Survey (NFHS-5). Factsheet. India; 2021."),
      body("14. Harper DM, Navarro-Alonso JA, Bosch FX, et al. Impact of HPV vaccines in reduction of infection, precursor lesions, and cervical cancer: A systematic review. Hum Vaccin Immunother. 2025. PMID: 40485552"),
      body("15. ICMR. National Ethical Guidelines for Biomedical and Health Research Involving Human Participants. New Delhi: ICMR; 2017."),

    ]
  }]
});

Packer.toBuffer(doc).then(buffer => {
  fs.writeFileSync('/home/daytona/workspace/hpv-protocol/HPV_Vaccination_KAP_Protocol.docx', buffer);
  console.log('SUCCESS: Document created');
}).catch(err => {
  console.error('ERROR:', err);
  process.exit(1);
});

from reportlab.lib.pagesizes import A4
from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle
from reportlab.lib.units import cm
from reportlab.lib import colors
from reportlab.platypus import (
    SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle,
    HRFlowable, PageBreak, KeepTogether
)
from reportlab.lib.enums import TA_LEFT, TA_CENTER, TA_JUSTIFY
from reportlab.platypus import Frame, PageTemplate

# ── Output path ──────────────────────────────────────────────────────────────
OUTPUT = "/home/daytona/hpv-out/HPV_KAP_Protocol_Full.pdf"

# ── Colors ───────────────────────────────────────────────────────────────────
DARK_BLUE   = colors.HexColor("#1F3864")
MID_BLUE    = colors.HexColor("#2E74B5")
LIGHT_BLUE  = colors.HexColor("#EBF3FB")
HEADER_BG   = colors.HexColor("#2E74B5")
ROW_ALT     = colors.HexColor("#F0F6FC")
WHITE       = colors.white
BLACK       = colors.black
GREY_LINE   = colors.HexColor("#CCCCCC")

# ── Styles ───────────────────────────────────────────────────────────────────
styles = getSampleStyleSheet()

def make_style(name, parent="Normal", **kwargs):
    return ParagraphStyle(name, parent=styles[parent], **kwargs)

Title       = make_style("Title",      fontSize=22, textColor=DARK_BLUE,
                          alignment=TA_CENTER, spaceAfter=6, leading=28, fontName="Helvetica-Bold")
SubTitle    = make_style("SubTitle",   fontSize=13, textColor=MID_BLUE,
                          alignment=TA_CENTER, spaceAfter=4, leading=18, fontName="Helvetica")
H1          = make_style("H1",         fontSize=13, textColor=DARK_BLUE,
                          spaceBefore=14, spaceAfter=4, leading=18, fontName="Helvetica-Bold")
H2          = make_style("H2",         fontSize=11, textColor=MID_BLUE,
                          spaceBefore=10, spaceAfter=3, leading=16, fontName="Helvetica-Bold")
Body        = make_style("Body",       fontSize=10, textColor=BLACK,
                          spaceAfter=6, leading=15, alignment=TA_JUSTIFY, fontName="Helvetica")
BodyBold    = make_style("BodyBold",   fontSize=10, textColor=BLACK,
                          spaceAfter=4, leading=15, fontName="Helvetica-Bold")
Bullet      = make_style("Bullet",     fontSize=10, textColor=BLACK,
                          leftIndent=16, spaceAfter=3, leading=14,
                          bulletIndent=4, fontName="Helvetica")
RefStyle    = make_style("RefStyle",   fontSize=9,  textColor=colors.HexColor("#333333"),
                          spaceAfter=3, leading=13, alignment=TA_JUSTIFY, fontName="Helvetica")
TCell       = make_style("TCell",      fontSize=9,  textColor=BLACK,
                          leading=13, fontName="Helvetica")
TCellH      = make_style("TCellH",     fontSize=9,  textColor=WHITE,
                          leading=13, fontName="Helvetica-Bold")
TitlePage   = make_style("TitlePage",  fontSize=11, textColor=BLACK,
                          alignment=TA_CENTER, spaceAfter=3, leading=16, fontName="Helvetica")

def hr(): return HRFlowable(width="100%", thickness=1, color=GREY_LINE, spaceAfter=8, spaceBefore=8)
def sp(h=6): return Spacer(1, h)

def bullet_item(text):
    return Paragraph(f"\u2022\u00a0\u00a0{text}", Bullet)

def table(data, col_widths=None, header=True):
    t = Table(data, colWidths=col_widths, repeatRows=1 if header else 0)
    style = [
        ("BACKGROUND", (0,0), (-1,0), HEADER_BG),
        ("TEXTCOLOR",  (0,0), (-1,0), WHITE),
        ("FONTNAME",   (0,0), (-1,0), "Helvetica-Bold"),
        ("FONTSIZE",   (0,0), (-1,-1), 9),
        ("GRID",       (0,0), (-1,-1), 0.4, GREY_LINE),
        ("ROWBACKGROUNDS", (0,1), (-1,-1), [WHITE, ROW_ALT]),
        ("VALIGN",     (0,0), (-1,-1), "TOP"),
        ("LEFTPADDING",(0,0), (-1,-1), 6),
        ("RIGHTPADDING",(0,0),(-1,-1), 6),
        ("TOPPADDING", (0,0), (-1,-1), 4),
        ("BOTTOMPADDING",(0,0),(-1,-1), 4),
    ]
    t.setStyle(TableStyle(style))
    return t

def p(text, style=Body): return Paragraph(text, style)
def h1(text): return p(text, H1)
def h2(text): return p(text, H2)
def bb(text): return p(text, BodyBold)

# ── Page header/footer ───────────────────────────────────────────────────────
def header_footer(canvas, doc):
    canvas.saveState()
    w, h = A4
    # Header bar
    canvas.setFillColor(DARK_BLUE)
    canvas.rect(1.5*cm, h-1.4*cm, w-3*cm, 0.55*cm, fill=1, stroke=0)
    canvas.setFillColor(WHITE)
    canvas.setFont("Helvetica-Bold", 8)
    canvas.drawString(1.8*cm, h-1.18*cm, "HPV Vaccination KAP Study Protocol")
    canvas.setFont("Helvetica", 8)
    canvas.drawRightString(w-1.5*cm, h-1.18*cm, "Anand, Gujarat  |  Pharm.D 5th Year Project")
    # Footer
    canvas.setFillColor(colors.HexColor("#555555"))
    canvas.setFont("Helvetica", 8)
    canvas.drawString(1.5*cm, 1.0*cm, "Confidential - For IEC Submission Only")
    canvas.drawRightString(w-1.5*cm, 1.0*cm, f"Page {doc.page}")
    canvas.restoreState()

# ── Build content ─────────────────────────────────────────────────────────────
story = []

# ════════════════════════════════════════════════════════════
# TITLE PAGE
# ════════════════════════════════════════════════════════════
story += [
    sp(60),
    p("RESEARCH PROTOCOL", ParagraphStyle("TP1", fontSize=28, textColor=DARK_BLUE,
       alignment=TA_CENTER, fontName="Helvetica-Bold", spaceAfter=8, leading=34)),
    HRFlowable(width="60%", thickness=2, color=MID_BLUE, spaceAfter=16, spaceBefore=8),
    p("Community-Based Assessment of Knowledge, Attitudes, Perceived Barriers, and Acceptance of Human Papillomavirus (HPV) Vaccination: Tool Validation and Health Education Resource Development",
      ParagraphStyle("TP2", fontSize=14, textColor=DARK_BLUE, alignment=TA_CENTER,
                     fontName="Helvetica-Bold", leading=20, spaceAfter=30)),
    sp(20),
    p("Principal Investigator: [Student Name], Pharm.D 5th Year", TitlePage),
    p("Guide: [Faculty Name], Department of Pharmacy Practice", TitlePage),
    p("Institution: [College Name], Anand, Gujarat", TitlePage),
    p("Duration: [Start Month, Year] to [End Month, Year] (6 months)", TitlePage),
    sp(8),
    p("Submitted to: Institutional Ethics Committee (IEC)", TitlePage),
    sp(60),
    HRFlowable(width="80%", thickness=1, color=GREY_LINE, spaceAfter=8),
    p("This protocol is prepared as part of the Pharm.D 5th Year Observational Research Project curriculum.",
      ParagraphStyle("footer_note", fontSize=9, textColor=colors.grey, alignment=TA_CENTER,
                     fontName="Helvetica")),
    PageBreak()
]

# ════════════════════════════════════════════════════════════
# 1. INTRODUCTION
# ════════════════════════════════════════════════════════════
story += [
    h1("1. INTRODUCTION"),
    hr(),
    p("Human Papillomavirus (HPV) is a small, non-enveloped, double-stranded DNA virus with over 200 known genotypes, of which approximately 14 are classified as high-risk or oncogenic types.<sup>1</sup> HPV types are broadly divided into low-risk types (6, 11) causing genital warts, and high-risk types (16, 18, 31, 33, 45, 52, 58) associated with malignant transformation.<sup>2</sup> Type 16 alone accounts for approximately 50-60% of all cervical cancers, while types 16 and 18 together are responsible for nearly 70% of cases globally.<sup>3</sup>"),
    sp(4),
    p("The oncogenic mechanism involves two key viral proteins: E6, which degrades the tumour suppressor p53, and E7, which inactivates the retinoblastoma protein (pRb), together driving uncontrolled cell cycle progression and genomic instability.<sup>4</sup> This progression from normal epithelium to cervical intraepithelial neoplasia (CIN) and ultimately invasive carcinoma typically spans 10 to 15 years, offering a wide preventive window.<sup>4</sup> In most individuals, HPV infection is transient and self-cleared within 1-2 years; persistent infection with high-risk types is what drives malignant transformation.<sup>1</sup>"),
    sp(4),
    p("Globally, cervical cancer is the fifth most common cancer in women, with 604,000 new cases and 280,000 deaths in 2024, over 90% of which occur in low- and middle-income countries.<sup>5</sup> The WHO's 90-70-90 elimination strategy by 2030 calls for 90% of girls to be vaccinated with HPV vaccine by age 15 as its primary pillar.<sup>5</sup> As of 2025, eight licensed HPV vaccines are available globally, all protecting against types 16 and 18. These include the bivalent Cervarix, quadrivalent Gardasil, nonavalent Gardasil-9, and India's own indigenous quadrivalent vaccine Cervavac (Serum Institute of India, targeting HPV 6, 11, 16, 18), indicated for females aged 9-26 years on a 2-dose schedule at ages 9-14 and a 3-dose schedule at ages 15-26.<sup>6</sup> Systematic review evidence confirms vaccine effectiveness is highest when administered at 9-14 years before HPV exposure.<sup>7</sup>"),
    sp(4),
    p("Despite evidence of vaccine efficacy, community acceptance remains a critical bottleneck in India, where sociocultural barriers, safety misconceptions, and limited awareness continue to impede uptake. This study was conceived to systematically assess these community-level barriers in Anand, Gujarat, while developing validated, locally appropriate tools and health education resources."),
]

# ════════════════════════════════════════════════════════════
# 2. REVIEW OF LITERATURE
# ════════════════════════════════════════════════════════════
story += [
    sp(10), h1("2. REVIEW OF LITERATURE"), hr(),

    h2("2.1 Studies Among Healthcare Providers"),
    p("Aggarwal et al. (2025) surveyed 399 healthcare providers at a tertiary care centre in North Delhi and found that while 95.9% of doctors were aware of HPV, only 66.7% of nurses and 73.4% of paramedical staff had equivalent knowledge. Despite 89.34% of doctors expressing confidence in vaccine safety, only 11.67% had personally received the HPV vaccine, and fewer than 9% of nursing staff were vaccinated - with affordability and lack of awareness as primary barriers.<sup>8</sup> Mandal et al. (2024), at AIIMS Kalyani, found good knowledge among 85.5% of doctors and 70.2% of nursing officers, yet the overall good practice score was critically low at just 31.3%, highlighting a persistent knowledge-to-action gap.<sup>9</sup> Kavyarani et al. (2025) reported that less than 50% of medical professionals could correctly identify all HPV vaccine target age groups or dosing schedules across South India.<sup>10</sup>"),

    sp(6), h2("2.2 Studies Among Community and Rural Populations"),
    p("Gandhi et al. (2024) conducted the most directly relevant published study - a mixed-methods KAP study among 400 rural women in Gujarat. Only 27% had heard of cervical cancer, 83% demonstrated poor knowledge, and critically, none of the 400 participants had ever received the HPV vaccine. Despite 64% expressing positive attitudes, only 9% had undergone cervical cancer screening. Stigma, gender roles, spousal communication gaps, and access barriers emerged as dominant themes.<sup>11</sup> Ganeshkumar et al. (2025), in a 15-state survey of 451 gynecologists and practitioners, found that patients consistently presented with misconceptions about personal risk and vaccine safety, and identified social media, digital platforms, and visual aids as the most effective channels for patient education.<sup>12</sup>"),

    sp(6), h2("2.3 Marginalized and Culturally Vulnerable Populations"),
    p("Vasudevan et al. (2026) conducted a multi-site qualitative study across Delhi-NCR, Tripura, and Karnataka among 89 marginalized individuals. Only 14 of 89 participants had ever heard of the HPV vaccine. Concerns about side effects, fertility, moral beliefs, and confusion from the COVID-19 vaccination experience drove hesitancy. Gendered decision-making was strongly present, with most women requiring husband or senior family member consent before accepting vaccination.<sup>13</sup> Mullassery and Posmontier (2024) further identified that traditional Indian health beliefs - including stigma around sexually transmitted infections - significantly reduced parental willingness to vaccinate daughters, even among educated communities.<sup>14</sup>"),

    sp(6), h2("2.4 Post-Rollout Evidence and Misinformation"),
    p("India's national HPV vaccination program was launched in November 2024 after over a decade of delay. Initial single-dose coverage reached only 22%, severely hampered by a mid-November 2024 social media campaign falsely claiming the vaccine contained toxic substances from aborted foetal tissues.<sup>15</sup> This demonstrates that even in the presence of a functional national program, community misinformation and low awareness can cripple uptake - making local KAP data from newly covered regions like Anand essential."),

    sp(6), h2("2.5 Gaps in Existing Literature"),
    p("Most Indian KAP studies are hospital-based, rely on non-validated questionnaires without linguistic adaptation, and have not been conducted at the community level in Gujarat post-2024 rollout. No published study has separately assessed HPV vaccination KAP among college students and parents as distinct target groups in this setting. A validated, bilingual (English/Gujarati) KAP tool and locally relevant health education materials for the Anand community are entirely absent from the existing literature."),
]

# ════════════════════════════════════════════════════════════
# 3. NEED OF THE STUDY
# ════════════════════════════════════════════════════════════
story += [
    sp(10), h1("3. NEED OF THE STUDY"), hr(),
    p("India accounts for approximately 25% of all global cervical cancer deaths, with one woman dying from the disease every eight minutes.<sup>15</sup> National cervical cancer screening coverage remains at a critically low 2% as per NFHS-5.<sup>16</sup> Despite the November 2024 launch of the national HPV vaccination program using the indigenous Cervavac vaccine for girls aged 9-14 years, initial coverage has collapsed to just 22% - driven by misinformation, cultural taboos, and a fundamental lack of community awareness.<sup>15</sup> Addressing this gap requires understanding what specific knowledge deficits, attitudes, and perceived barriers exist at the ground level in communities like Anand, Gujarat."),
    sp(4),
    p("Existing research confirms that the knowledge gap is profound even among healthcare providers,<sup>8,9</sup> and is far more severe in community and rural populations.<sup>11,13</sup> Yet no published community-level KAP data exists from Anand district, and virtually no study has collected this data following the 2024 national rollout. Most existing Indian studies use non-validated, non-standardized questionnaires that have not been linguistically adapted for Gujarati-speaking populations, making their findings unreliable for guiding local policy. Additionally, there is a complete absence of validated, culturally appropriate, Gujarati-language health education resources on HPV vaccination that can be practically deployed in community settings by healthcare workers, pharmacists, or volunteers."),
    sp(4),
    p("This study is therefore urgently needed to generate community-specific, post-rollout KAP data from Anand, Gujarat; to fill the methodological gap by developing and validating a bilingual questionnaire; and to produce ready-to-use health education materials that translate evidence into community action."),
]

# ════════════════════════════════════════════════════════════
# 4. RATIONALE OF THE STUDY
# ════════════════════════════════════════════════════════════
story += [
    sp(10), h1("4. RATIONALE OF THE STUDY"), hr(),
    p("While the global and national evidence base confirms the efficacy of HPV vaccination and the existence of serious community-level barriers to its acceptance, no study has yet addressed this problem specifically within the community of Anand, Gujarat. The district's semi-urban demographic profile - with mixed educational attainment, co-existing traditional health beliefs, and a newly established national vaccination program - presents a unique and timely setting for this investigation."),
    sp(4),
    p("Two distinct community groups - college students and parents of girls aged 9-18 years - have been identified as primary target populations because they represent complementary decision-making perspectives: students as potential vaccine recipients themselves, and parents as the primary consent-givers for the eligible 9-14 year age group. Assessing both groups simultaneously, using separate, tailored questionnaires, is a methodological approach that no published Indian study has yet adopted for this topic, making it a key novelty of this project."),
    sp(4),
    p("Furthermore, pharmacy students at the 5th year Pharm.D level are uniquely positioned as frontline community health educators, given their training in patient counselling, pharmacology, and public health. This project leverages that positioning to not only generate evidence but also directly produce validated tools and health education resources that can be reused by future researchers, community health workers, and local health authorities - directly contributing to India's national goal of achieving 90% HPV vaccination coverage by 2030.<sup>5</sup>"),
]

# ════════════════════════════════════════════════════════════
# 5. OBJECTIVES
# ════════════════════════════════════════════════════════════
story += [
    sp(10), h1("5. OBJECTIVES"), hr(),
    h2("5.1 Primary Objectives"),
    bullet_item("To assess the knowledge, attitudes, perceived barriers, and acceptance of HPV vaccination among college students and parents of girls aged 9-18 years in Anand, Gujarat."),
    bullet_item("To develop and validate two separate bilingual (English/Gujarati) KAP questionnaires - one for college students and one for parents."),
    sp(4), h2("5.2 Secondary Objectives"),
    bullet_item("To identify sociodemographic factors associated with HPV vaccination knowledge and acceptance in each study arm."),
    bullet_item("To compare KAP profiles between college students and parents."),
    bullet_item("To develop a culturally appropriate bilingual health education leaflet/poster on HPV vaccination for community use."),
    bullet_item("To assess the readability and acceptability of the developed health education resource."),
]

# ════════════════════════════════════════════════════════════
# 6. METHODOLOGY
# ════════════════════════════════════════════════════════════
story += [
    sp(10), h1("6. METHODOLOGY"), hr(),

    h2("6.1 Study Design"),
    p("Cross-sectional, community-based observational study with an embedded tool validation component."),

    sp(4), h2("6.2 Study Setting"),
    p("Residential areas, colleges, community health centres, PHCs, and Anganwadi centres in Anand district, Gujarat."),

    sp(4), h2("6.3 Study Duration"),
    p("6 months - including tool development, validation, data collection, analysis, and health education resource development."),

    sp(4), h2("6.4 Study Population - Two Arms"),
    table(
        [
            [p("", TCellH), p("Arm 1: College Students", TCellH), p("Arm 2: Parents", TCellH)],
            [p("Who", TCell), p("Students enrolled in colleges in Anand", TCell), p("Parents of girls aged 9-18 years in Anand", TCell)],
            [p("Age", TCell), p("18-25 years", TCell), p("25-55 years (approx.)", TCell)],
            [p("Rationale", TCell), p("Near target age group; personal acceptance", TCell), p("Primary decision-makers for daughter's vaccination", TCell)],
            [p("Recruitment", TCell), p("College campuses", TCell), p("PHCs, Anganwadis, residential areas", TCell)],
        ],
        col_widths=[3*cm, 7.5*cm, 7.5*cm]
    ),

    sp(6), h2("6.5 Sample Size"),
    p("Formula: n = Z\u00b2 \u00d7 p \u00d7 (1-p) / d\u00b2"),
    p("Z = 1.96 (95% CI); p = 0.50 (conservative estimate); d = 0.07 (margin of error)"),
    p("n = (1.96)\u00b2 \u00d7 0.5 \u00d7 0.5 / (0.07)\u00b2 \u2248 196 per arm; adding 10% non-response = <b>~216 per arm</b>"),
    p("<b>Total sample = ~432 participants (216 students + 216 parents)</b>"),

    sp(4), h2("6.6 Inclusion & Exclusion Criteria"),
    table(
        [
            [p("Criterion", TCellH), p("Arm 1: Students", TCellH), p("Arm 2: Parents", TCellH)],
            [p("Age", TCell), p("18-25 years", TCell), p("\u226525 years", TCell)],
            [p("Specific", TCell), p("Enrolled in college in Anand", TCell), p("Parent of girl aged 9-18 years", TCell)],
            [p("Residence", TCell), p("Anand district \u22656 months", TCell), p("Anand district \u22656 months", TCell)],
            [p("Exclusion", TCell), p("Healthcare professionals; cognitive impairment; refusal of consent", TCell), p("Healthcare professionals; cognitive impairment; refusal of consent", TCell)],
        ],
        col_widths=[3*cm, 7.5*cm, 7.5*cm]
    ),
]

# ════════════════════════════════════════════════════════════
# 7. DATA COLLECTION TOOL
# ════════════════════════════════════════════════════════════
story += [
    sp(10), h1("7. DATA COLLECTION TOOL"), hr(),
    h2("7.1 Questionnaire Structure"),
    p("Two structured questionnaires will be developed de novo in English and translated into Gujarati using forward-backward translation methodology. Both share a common core structure but with population-specific items:"),
    sp(4),
    table(
        [
            [p("Section", TCellH), p("Content", TCellH), p("Students", TCellH), p("Parents", TCellH)],
            [p("A", TCell), p("Sociodemographic information", TCell), p("8 items", TCell), p("8 items", TCell)],
            [p("B", TCell), p("Knowledge of HPV and cervical cancer", TCell), p("15 items (MCQ/True-False)", TCell), p("15 items (MCQ/True-False)", TCell)],
            [p("C", TCell), p("Attitudes toward HPV vaccination", TCell), p("10 items (5-pt Likert)", TCell), p("10 items (5-pt Likert)", TCell)],
            [p("D", TCell), p("Perceived barriers", TCell), p("10 items (5-pt Likert)", TCell), p("10 items (5-pt Likert)", TCell)],
            [p("E", TCell), p("Vaccine acceptance", TCell), p("5 items (personal)", TCell), p("5 items (intent to vaccinate daughter)", TCell)],
        ],
        col_widths=[1.5*cm, 5.5*cm, 5*cm, 6*cm]
    ),
    sp(6), h2("7.2 Validation Steps"),
    table(
        [
            [p("Step", TCellH), p("Method", TCellH), p("Threshold", TCellH)],
            [p("Content Validity", TCell), p("Expert panel of 5-7 (physicians, pharmacists, public health experts) - Content Validity Index (CVI)", TCell), p("CVI \u22650.80", TCell)],
            [p("Face Validity", TCell), p("Pilot testing on 15 community members for language clarity", TCell), p("Majority comprehension confirmed", TCell)],
            [p("Internal Consistency", TCell), p("Cronbach's alpha for attitude and barrier subscales", TCell), p("\u03b1 \u22650.70", TCell)],
            [p("Test-Retest Reliability", TCell), p("Re-administration to 30 participants after 2 weeks", TCell), p("ICC \u22650.75", TCell)],
        ],
        col_widths=[4*cm, 10*cm, 4*cm]
    ),
]

# ════════════════════════════════════════════════════════════
# 8. HEALTH EDUCATION RESOURCE
# ════════════════════════════════════════════════════════════
story += [
    sp(10), h1("8. HEALTH EDUCATION RESOURCE DEVELOPMENT"), hr(),
    p("A bilingual (Gujarati/Hindi) health education leaflet will be developed covering:"),
    bullet_item("What is HPV and how is it transmitted?"),
    bullet_item("Link between HPV and cervical cancer"),
    bullet_item("Who should receive the HPV vaccine and when?"),
    bullet_item("Government's free national vaccination program (Cervavac) details"),
    bullet_item("Addressing common myths and misconceptions"),
    bullet_item("Where to get vaccinated in Anand district"),
    sp(4),
    p("The leaflet will be reviewed by an expert panel for content accuracy and by 20 community members for readability and acceptability. Readability will be assessed using a validated checklist and acceptability rated on a 5-point scale."),
]

# ════════════════════════════════════════════════════════════
# 9. STATISTICAL ANALYSIS
# ════════════════════════════════════════════════════════════
story += [
    sp(10), h1("9. STATISTICAL ANALYSIS PLAN"), hr(),
    p("Data will be entered in Microsoft Excel and analyzed using SPSS v26 or JASP (free software)."),
    sp(4),
    table(
        [
            [p("Analysis", TCellH), p("Purpose", TCellH)],
            [p("Descriptive statistics (frequency, mean, SD)", TCell), p("Summarize sociodemographic data and KAP scores", TCell)],
            [p("Chi-square test", TCell), p("Association between sociodemographic variables and KAP", TCell)],
            [p("Independent t-test / ANOVA", TCell), p("Compare KAP scores across groups and between arms", TCell)],
            [p("Pearson/Spearman correlation", TCell), p("Correlation between knowledge, attitude, and acceptance scores", TCell)],
            [p("Binary logistic regression", TCell), p("Predictors of HPV vaccine acceptance", TCell)],
        ],
        col_widths=[9*cm, 9*cm]
    ),
    sp(4),
    p("Knowledge scores: Poor (<50%), Moderate (50-74%), Good (\u226575%). p-value <0.05 considered statistically significant."),
]

# ════════════════════════════════════════════════════════════
# 10. ETHICAL CONSIDERATIONS
# ════════════════════════════════════════════════════════════
story += [
    sp(10), h1("10. ETHICAL CONSIDERATIONS"), hr(),
    bullet_item("IEC approval will be obtained prior to study initiation."),
    bullet_item("Written informed consent will be taken from all participants."),
    bullet_item("Participation is voluntary; participants may withdraw at any time without penalty."),
    bullet_item("Anonymity and confidentiality of participant data will be strictly maintained."),
    bullet_item("No biological samples or interventions will be performed - purely observational study."),
    bullet_item("Study will adhere to ICMR National Ethical Guidelines for Biomedical and Health Research Involving Human Participants (2017)."),
]

# ════════════════════════════════════════════════════════════
# 11. EXPECTED OUTCOMES & LIMITATIONS
# ════════════════════════════════════════════════════════════
story += [
    sp(10), h1("11. EXPECTED OUTCOMES"), hr(),
    bullet_item("Two validated bilingual (English/Gujarati) KAP questionnaires on HPV vaccination."),
    bullet_item("Community-level KAP data from Anand, Gujarat post-2024 national rollout."),
    bullet_item("Identification of key sociodemographic predictors of vaccine acceptance."),
    bullet_item("A ready-to-distribute, expert-validated bilingual health education leaflet on HPV vaccination."),

    sp(10), h1("12. LIMITATIONS"), hr(),
    bullet_item("Self-reported data may be subject to social desirability bias."),
    bullet_item("Cross-sectional design limits causal inference."),
    bullet_item("Convenience sampling in Arm 1 may limit generalizability."),
    bullet_item("Study restricted to Anand district; findings may not represent all of Gujarat."),
]

# ════════════════════════════════════════════════════════════
# 13. REFERENCES
# ════════════════════════════════════════════════════════════
story += [
    PageBreak(),
    h1("13. REFERENCES"), hr(),
    p("1. WHO. Human papillomavirus and cancer. Geneva: WHO; 2024. Available from: https://www.who.int/news-room/fact-sheets/detail/human-papilloma-virus-and-cancer", RefStyle),
    p("2. FOGSI. Preventing Cervical Cancer through HPV Vaccination in India. 2024.", RefStyle),
    p("3. HPV Information Centre. HPV and Related Diseases Report: India. IARC/ICO; 2023. Available from: https://hpvcentre.net/statistics/reports/IND.pdf", RefStyle),
    p("4. Palomino-Vizcaino G, et al. The Natural History of Cervical Cancer and the Case for MicroRNAs. Int J Mol Sci. 2024. [PMID: 39684702]", RefStyle),
    p("5. World Health Organization. Cervical cancer. Geneva: WHO; 2024. Available from: https://www.who.int/news-room/fact-sheets/detail/cervical-cancer", RefStyle),
    p("6. Serum Institute of India. Cervavac: Vaccine Information. 2024. Available from: https://cervavac.com", RefStyle),
    p("7. Ellingson MK, Sheikha H, Nyhan K, et al. HPV vaccine effectiveness by age at vaccination: A systematic review. Hum Vaccin Immunother. 2023;19(2):2239085. [PMID: 37529935]", RefStyle),
    p("8. Aggarwal I, Mehta D, Yadav P, et al. KAP on HPV Vaccination among Healthcare Providers at a Tertiary Care Centre in North Delhi. Asian Pac J Cancer Prev. 2025;26(2):671. [PMID: 40022716]", RefStyle),
    p("9. Mandal M, Sarkar S, Panda S. KAP of Young Female Nursing Officers and Female Doctors About the HPV Vaccine. Cureus. 2024. doi:10.7759/cureus.66284 [PMID: 39238704]", RefStyle),
    p("10. Kavyarani C, Kannan Karur A, Chaitra C, et al. KAP of Medical Professionals Regarding Cervical Cancer Prevention and HPV Vaccination. Cureus. 2025. [PMID: 41063879]", RefStyle),
    p("11. Gandhi R, Patel A, Patel M, et al. Cervical Cancer Prevention Among Rural Women in Gujarat: A Mixed Methods KAP Study. Cureus. 2024. doi:10.7759/cureus.69169 [PMID: 39398714]", RefStyle),
    p("12. Ganeshkumar P, Tank J, Choudhury SS, et al. KAP Study on Cervical Cancer Prevention and HPV Vaccination. South Asian J Cancer. 2025. [PMID: 41445902]", RefStyle),
    p("13. Vasudevan U, Kelly-Hanku A, Limbu P, et al. Marginalized voices on HPV vaccination in India. Front Glob Womens Health. 2026. [PMID: 42100579]", RefStyle),
    p("14. Mullassery D, Posmontier B. Health beliefs and acculturation on HPV vaccination acceptance among Asian Indian parents. J Am Assoc Nurse Pract. 2024. [PMID: 39264332]", RefStyle),
    p("15. Gavi. India, home to 25% of world's cervical cancer deaths, launches nationwide HPV vaccination. 2025. Available from: https://www.gavi.org/vaccineswork/india-home-25-worlds-cervical-cancer-victims-launches-nationwide-hpv-vaccination", RefStyle),
    p("16. National Family Health Survey (NFHS-5). Factsheet. India; 2021.", RefStyle),
    p("17. Harper DM, Navarro-Alonso JA, Bosch FX, et al. Impact of HPV vaccines in reduction of infection, precursor lesions, and cervical cancer. Hum Vaccin Immunother. 2025. [PMID: 40485552]", RefStyle),
    p("18. ICMR-NICPR. Cancer Statistics India. Available from: https://cancerindia.org.in/statistics", RefStyle),
    p("19. Nelson CW, Mirabello L. HPV genomics: Understanding carcinogenicity. Tumour Virus Res. 2023. [PMID: 36812987]", RefStyle),
]

# ── Build PDF ─────────────────────────────────────────────────────────────────
doc = SimpleDocTemplate(
    OUTPUT,
    pagesize=A4,
    leftMargin=1.8*cm,
    rightMargin=1.8*cm,
    topMargin=2.2*cm,
    bottomMargin=2.0*cm,
    title="HPV Vaccination KAP Study Protocol",
    author="Pharm.D 5th Year Student, Anand Gujarat",
)

doc.build(story, onFirstPage=header_footer, onLaterPages=header_footer)
print(f"SUCCESS: PDF created at {OUTPUT}")

from reportlab.lib.pagesizes import A4
from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle
from reportlab.lib.units import cm
from reportlab.lib import colors
from reportlab.platypus import (
    SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle,
    HRFlowable, PageBreak, KeepTogether
)
from reportlab.lib.enums import TA_LEFT, TA_CENTER, TA_JUSTIFY

OUTPUT = "/home/daytona/hpv-out/HPV_KAP_Questionnaires.pdf"

# Colors
DARK_BLUE  = colors.HexColor("#1F3864")
MID_BLUE   = colors.HexColor("#2E74B5")
LIGHT_BLUE = colors.HexColor("#EBF3FB")
GREEN      = colors.HexColor("#1D6B2E")
ORANGE     = colors.HexColor("#C55A11")
RED_BOX    = colors.HexColor("#FDECEA")
BLUE_BOX   = colors.HexColor("#EBF3FB")
GREEN_BOX  = colors.HexColor("#E8F5E9")
GREY       = colors.HexColor("#CCCCCC")
WHITE      = colors.white
BLACK      = colors.black

styles = getSampleStyleSheet()

def sty(name, **kw):
    return ParagraphStyle(name, **kw)

Title    = sty("T",  fontSize=16, textColor=DARK_BLUE,  alignment=TA_CENTER, fontName="Helvetica-Bold", leading=22, spaceAfter=4)
SubT     = sty("ST", fontSize=10, textColor=MID_BLUE,   alignment=TA_CENTER, fontName="Helvetica",      leading=14, spaceAfter=2)
SecHead  = sty("SH", fontSize=12, textColor=WHITE,      fontName="Helvetica-Bold", leading=16, spaceAfter=0, spaceBefore=10)
QNum     = sty("QN", fontSize=10, textColor=DARK_BLUE,  fontName="Helvetica-Bold", leading=14, spaceAfter=1, spaceBefore=6)
QText    = sty("QT", fontSize=10, textColor=BLACK,      fontName="Helvetica",      leading=14, spaceAfter=1)
Opt      = sty("OP", fontSize=10, textColor=BLACK,      fontName="Helvetica",      leading=13, leftIndent=18, spaceAfter=1)
Note     = sty("NT", fontSize=8,  textColor=colors.HexColor("#555555"), fontName="Helvetica-Oblique", leading=11, spaceAfter=2)
Instr    = sty("IN", fontSize=9,  textColor=BLACK,      fontName="Helvetica",      leading=13, spaceAfter=4, alignment=TA_JUSTIFY)
Bold9    = sty("B9", fontSize=9,  textColor=BLACK,      fontName="Helvetica-Bold", leading=13, spaceAfter=2)
Filter   = sty("FL", fontSize=10, textColor=colors.HexColor("#7B1F1F"), fontName="Helvetica-Bold", leading=14, spaceAfter=2)
BoxText  = sty("BX", fontSize=9,  textColor=colors.HexColor("#1D4E1A"), fontName="Helvetica", leading=13, spaceAfter=2)

def hr(): return HRFlowable(width="100%", thickness=0.8, color=GREY, spaceAfter=6, spaceBefore=4)
def sp(h=6): return Spacer(1, h)

def section_header(text, color=MID_BLUE):
    data = [[Paragraph(text, SecHead)]]
    t = Table(data, colWidths=[18*cm])
    t.setStyle(TableStyle([
        ("BACKGROUND", (0,0), (-1,-1), color),
        ("LEFTPADDING",  (0,0),(-1,-1), 8),
        ("RIGHTPADDING", (0,0),(-1,-1), 8),
        ("TOPPADDING",   (0,0),(-1,-1), 5),
        ("BOTTOMPADDING",(0,0),(-1,-1), 5),
    ]))
    return t

def box(text, bg=BLUE_BOX, border=MID_BLUE):
    data = [[Paragraph(text, BoxText)]]
    t = Table(data, colWidths=[18*cm])
    t.setStyle(TableStyle([
        ("BACKGROUND",   (0,0),(-1,-1), bg),
        ("BOX",          (0,0),(-1,-1), 1, border),
        ("LEFTPADDING",  (0,0),(-1,-1), 8),
        ("RIGHTPADDING", (0,0),(-1,-1), 8),
        ("TOPPADDING",   (0,0),(-1,-1), 5),
        ("BOTTOMPADDING",(0,0),(-1,-1), 5),
    ]))
    return t

def q(num, text, note=None):
    items = [Paragraph(f"{num}.  {text}", QText)]
    if note:
        items.append(Paragraph(f"✎ {note}", Note))
    return items

def opts(*options):
    return [Paragraph(f"○  {o}", Opt) for o in options]

def tf_opts():
    return [Paragraph("○  TRUE        ○  FALSE        ○  DON'T KNOW", Opt)]

def likert_scale():
    return [Paragraph("1 = Strongly Disagree   2 = Disagree   3 = Neutral   4 = Agree   5 = Strongly Agree", Opt),
            Paragraph("○ 1          ○ 2          ○ 3          ○ 4          ○ 5", Opt)]

def barrier_scale():
    return [Paragraph("1 = Not at all   2 = Slightly   3 = Moderately   4 = Considerably   5 = Completely stops me", Opt),
            Paragraph("○ 1          ○ 2          ○ 3          ○ 4          ○ 5", Opt)]

def page_header(canvas, doc):
    canvas.saveState()
    w, h = A4
    canvas.setFillColor(DARK_BLUE)
    canvas.rect(1.5*cm, h-1.3*cm, w-3*cm, 0.5*cm, fill=1, stroke=0)
    canvas.setFillColor(WHITE)
    canvas.setFont("Helvetica-Bold", 8)
    canvas.drawString(1.8*cm, h-1.1*cm, "HPV Vaccination KAP Study  |  Anand, Gujarat  |  Pharm.D 5th Year")
    canvas.setFont("Helvetica", 8)
    canvas.drawRightString(w-1.5*cm, h-1.1*cm, f"Page {doc.page}")
    canvas.setFillColor(colors.HexColor("#555555"))
    canvas.setFont("Helvetica", 7)
    canvas.drawString(1.5*cm, 0.8*cm, "Confidential — For Research Use Only. All responses are anonymous.")
    canvas.restoreState()

story = []

# ══════════════════════════════════════════════════════════════
# COVER PAGE
# ══════════════════════════════════════════════════════════════
story += [
    sp(50),
    Paragraph("HPV VACCINATION KAP STUDY", sty("CP1", fontSize=22, textColor=DARK_BLUE, alignment=TA_CENTER, fontName="Helvetica-Bold", leading=28)),
    HRFlowable(width="50%", thickness=2, color=MID_BLUE, spaceAfter=10, spaceBefore=6),
    Paragraph("Community-Based Assessment of Knowledge, Attitudes,<br/>Perceived Barriers, and Acceptance of HPV Vaccination", sty("CP2", fontSize=13, textColor=MID_BLUE, alignment=TA_CENTER, fontName="Helvetica", leading=18, spaceAfter=20)),
    sp(20),
    Paragraph("RESEARCH QUESTIONNAIRES", sty("CP3", fontSize=14, textColor=DARK_BLUE, alignment=TA_CENTER, fontName="Helvetica-Bold", leading=18, spaceAfter=6)),
    Paragraph("Two Versions: College Students | Parents of Girls Aged 9–18 Years", sty("CP4", fontSize=11, textColor=MID_BLUE, alignment=TA_CENTER, fontName="Helvetica", leading=16, spaceAfter=30)),
    sp(30),
    box("Institution: [College Name], Anand, Gujarat\nDepartment: Pharmacy Practice  |  Program: Pharm.D 5th Year\nGuide: [Faculty Name]  |  Study Duration: [Month Year] to [Month Year]", BLUE_BOX, MID_BLUE),
    sp(20),
    box("⚠ Instructions for Researcher:\n• Administer in person or as a self-administered questionnaire.\n• Read aloud for participants with low literacy.\n• Ensure informed consent is obtained before starting.\n• Filter question B0 determines whether to read a brief HPV explanation before Sections C–E.\n• Do NOT suggest answers. Maintain neutrality throughout.", colors.HexColor("#FFF8E1"), colors.HexColor("#F9A825")),
    PageBreak()
]

# ══════════════════════════════════════════════════════════════
# QUESTIONNAIRE 1 - COLLEGE STUDENTS
# ══════════════════════════════════════════════════════════════
story += [
    Paragraph("QUESTIONNAIRE 1", sty("Q1H", fontSize=18, textColor=DARK_BLUE, fontName="Helvetica-Bold", leading=22, alignment=TA_CENTER)),
    Paragraph("For College Students (Age 18–25 years)", sty("Q1S", fontSize=12, textColor=MID_BLUE, fontName="Helvetica", leading=16, alignment=TA_CENTER, spaceAfter=6)),
    hr(),
    box("Instructions: Please read each question carefully and answer honestly. There are no right or wrong answers. All responses are completely confidential. Estimated time: 10–12 minutes.", BLUE_BOX, MID_BLUE),
    sp(6),
]

# Section A
story += [section_header("SECTION A — Sociodemographic Information"), sp(4)]
sA = [
    ("A1", "Age: _______ years", None),
    ("A2", "Gender:", None),
    ("A3", "Course of study:", None),
    ("A4", "Year of study:", None),
    ("A5", "Religion:", None),
    ("A6", "Monthly family income (approximate):", None),
    ("A7", "Residence:", None),
    ("A8", "Have you ever attended any health awareness program on cancer or vaccination?", None),
]
aopts = [
    ["○ Male", "○ Female", "○ Prefer not to say"],
    ["○ Science / Pharmacy / Medical", "○ Arts / Commerce / Humanities", "○ Engineering / Technology", "○ Other: _______"],
    ["○ 1st Year  ○ 2nd Year  ○ 3rd Year  ○ 4th Year  ○ 5th Year / PG"],
    ["○ Hindu  ○ Muslim  ○ Christian  ○ Jain  ○ Other: _______"],
    ["○ Below ₹10,000  ○ ₹10,000–₹25,000  ○ ₹25,001–₹50,000  ○ Above ₹50,000"],
    ["○ Urban  ○ Semi-urban  ○ Rural"],
    ["○ Yes  ○ No"],
]
for i, (num, text, note) in enumerate(sA):
    story += q(num, text, note)
    if i > 0:
        story += [Paragraph("   " + aopts[i-1][0] if len(aopts[i-1])==1 else "   " + "     ".join(aopts[i-1]), Opt)]
    story += [sp(2)]

# Section B Filter
story += [sp(6), section_header("SECTION B — Knowledge of HPV and Cervical Cancer", DARK_BLUE), sp(4)]
story += [
    box("⚠ FILTER QUESTION — Must be asked FIRST before any other knowledge question.", RED_BOX, colors.HexColor("#C62828")),
    sp(4),
    Paragraph("B0.  Have you ever heard of HPV (Human Papillomavirus) or HPV vaccination before this survey?", Filter),
    Paragraph("○  Yes, I have heard of it and know something about it", Opt),
    Paragraph("○  I have heard the name but I do not know what it means", Opt),
    Paragraph("○  No, I have never heard of HPV or HPV vaccination before today", Opt),
    sp(4),
    box("📋 Researcher Instruction:\n✔ If participant selects 'Yes' → Proceed directly to B1–B15.\n✔ If participant selects 'Heard name only' or 'No' → Read the following statement aloud, then SKIP to Section C:\n\n\"HPV stands for Human Papillomavirus. It is a common infection that can cause cervical cancer in women. A safe vaccine is now available free of cost from the Government of India for girls aged 9 to 14 years.\"\n\nNote: Even participants with no prior awareness should complete Sections C, D, and E — their attitudes and acceptance are still valid and important research data.", GREEN_BOX, GREEN),
    sp(6),
    Paragraph("Instructions for B1–B15: Circle TRUE, FALSE, or DON'T KNOW for each statement.", Instr),
    Paragraph("(Only for participants who answered 'Yes' to B0)", Note),
    sp(4),
]

# B1-B15
bqs = [
    ("B1",  "HPV infection always leads to cervical cancer in every woman infected.",                         "Correct: FALSE — most HPV infections clear on their own"),
    ("B2",  "A person can have HPV infection for years without showing any symptoms.",                         "Correct: TRUE"),
    ("B3",  "HPV can only affect women — men cannot get HPV infection.",                                      "Correct: FALSE — affects men too"),
    ("B4",  "The HPV vaccine is recommended primarily for women aged 18–25 years.",                           "Correct: FALSE — target age is 9–14 years"),
    ("B5",  "Once vaccinated against HPV, a woman never needs cervical cancer screening again.",              "Correct: FALSE — screening still needed"),
    ("B6",  "HPV types 16 and 18 cause the majority of cervical cancers worldwide.",                          "Correct: TRUE"),
    ("B7",  "The HPV vaccine protects against all 200+ types of HPV.",                                        "Correct: FALSE — only against selected high-risk types"),
    ("B8",  "A girl who has not yet become sexually active does not need the HPV vaccine.",                   "Correct: FALSE — best given before exposure"),
    ("B9",  "India has its own domestically manufactured HPV vaccine called Cervavac.",                       "Correct: TRUE"),
    ("B10", "The HPV vaccine can treat or cure an existing HPV infection.",                                   "Correct: FALSE — it is preventive only"),
    ("B11", "Boys and men cannot benefit from HPV vaccination.",                                              "Correct: FALSE — they can be vaccinated too"),
    ("B12", "Cervical cancer can be completely prevented by HPV vaccination alone without any screening.",    "Correct: FALSE — screening is also necessary"),
    ("B13", "The Government of India provides HPV vaccination free of cost under its national program.",      "Correct: TRUE"),
    ("B14", "HPV is transmitted only through blood contact, like a blood transfusion.",                       "Correct: FALSE — transmitted through skin/mucosal contact"),
    ("B15", "Girls aged 9–14 years require only 2 doses of the HPV vaccine under the national schedule.",    "Correct: TRUE"),
]
for num, text, note in bqs:
    story += q(num, text, note) + tf_opts() + [sp(3)]

# Section C Students
story += [sp(6), section_header("SECTION C — Attitudes Toward HPV Vaccination"), sp(4)]
story += [Paragraph("Rate each statement from 1 (Strongly Disagree) to 5 (Strongly Agree).", Instr), sp(4)]
cqs_s = [
    ("C1",  "Giving a girl the HPV vaccine sends the wrong message about sexual behaviour.",                "Negative statement — disagreement = positive attitude"),
    ("C2",  "I would hesitate to take the HPV vaccine because it is relatively new and I don't trust it.", None),
    ("C3",  "HPV vaccination is not necessary for girls from well-educated or high-income families.",       "Negative statement"),
    ("C4",  "I think healthcare providers overestimate the need for HPV vaccination.",                      "Negative statement"),
    ("C5",  "I would follow my doctor's recommendation regarding the HPV vaccine.",                         None),
    ("C6",  "HPV vaccination is a personal choice — the government should not promote it actively.",        "Negative statement"),
    ("C7",  "I feel the HPV vaccine protects not just the individual but the whole community.",              None),
    ("C8",  "Information about HPV vaccine side effects on social media is more reliable than doctors' advice.", "Negative statement — tests critical thinking"),
    ("C9",  "I would recommend the HPV vaccine to a younger female relative aged 9–14 years.",              None),
    ("C10", "Cultural or religious concerns about HPV vaccination are valid enough reasons to avoid it.",   "Negative statement"),
]
for num, text, note in cqs_s:
    story += q(num, text, note) + likert_scale() + [sp(3)]

# Section D Students
story += [sp(6), section_header("SECTION D — Perceived Barriers to HPV Vaccination"), sp(4)]
story += [Paragraph("Rate how much each factor would prevent YOU from getting vaccinated (1 = Not at all, 5 = Completely stops me).", Instr), sp(4)]
dqs_s = [
    ("D1",  "I do not know where to get the HPV vaccine in my area.",                                       None),
    ("D2",  "I am afraid of injections in general.",                                                        None),
    ("D3",  "My family would disapprove if I got the HPV vaccine.",                                         None),
    ("D4",  "I have heard negative stories about HPV vaccine reactions from people I know or on social media.", None),
    ("D5",  "I think the vaccine is only for sexually active people, so it does not apply to me.",           None),
    ("D6",  "I feel embarrassed or uncomfortable discussing HPV vaccination with my parents or doctor.",    None),
    ("D7",  "The process of getting vaccinated (visiting a centre, multiple doses) feels too inconvenient.", None),
    ("D8",  "I am not convinced that the HPV vaccine will actually protect me.",                             None),
    ("D9",  "Nobody in my social circle has discussed or received the HPV vaccine.",                        None),
    ("D10", "I would only get the HPV vaccine if specifically told to by a doctor — I would not seek it myself.", None),
]
for num, text, note in dqs_s:
    story += q(num, text, note) + barrier_scale() + [sp(3)]

# Section E Students
story += [sp(6), section_header("SECTION E — Personal Acceptance of HPV Vaccination"), sp(4)]
eqs_s = [
    ("E1", "Have you already received the HPV vaccine?",
     ["○ Yes", "○ No", "○ Not sure"]),
    ("E2", "If a free HPV vaccine was available to you TODAY at a nearby centre, what would you do?",
     ["○ Go immediately without hesitation",
      "○ Go after discussing with family first",
      "○ Wait and think about it more",
      "○ Probably not go",
      "○ Definitely not go"]),
    ("E3", "Which statement best describes you right now?",
     ["○ I know about HPV vaccine and want to take it",
      "○ I know about HPV vaccine but I am unsure about taking it",
      "○ I know about HPV vaccine but I do not want to take it",
      "○ I did not know about HPV vaccine before this questionnaire"]),
    ("E4", "A friend tells you 'the HPV vaccine caused paralysis in a girl in my village.' What would you do?",
     ["○ Immediately decide not to take the vaccine",
      "○ Search for reliable information and consult a doctor before deciding",
      "○ Ask more people in the community before deciding",
      "○ Recognize it as likely misinformation and proceed with vaccination",
      "○ Share the story on social media as a warning to others"]),
    ("E5", "If your younger sister (aged 12) was offered a free HPV vaccine at her school, would you encourage her to take it?",
     ["○ Definitely yes",
      "○ Yes, after getting more information about it",
      "○ Not sure",
      "○ Probably not",
      "○ Definitely not — Reason: _______________________"]),
]
for num, text, options in eqs_s:
    story += q(num, text) + [Paragraph(o, Opt) for o in options] + [sp(4)]

story += [
    sp(6),
    box("Scoring Guide (For Researcher):\n• Section B: TRUE=1, FALSE=0, DON'T KNOW=0. Reverse score B3, B4, B5, B7, B8, B10, B11, B12, B14 (FALSE=1).\n  Poor knowledge: 0–7 | Moderate: 8–11 | Good: 12–15\n• Section C: Reverse score C1, C2, C3, C4, C6, C8, C10 (5=1, 4=2, 3=3, 2=4, 1=5).\n  Negative attitude: 10–25 | Neutral: 26–35 | Positive: 36–50\n• Section D: Higher total score = more barriers (range 10–50)\n• Section E: Descriptive frequency analysis", GREEN_BOX, GREEN),
    PageBreak()
]

# ══════════════════════════════════════════════════════════════
# QUESTIONNAIRE 2 - PARENTS
# ══════════════════════════════════════════════════════════════
story += [
    Paragraph("QUESTIONNAIRE 2", sty("Q2H", fontSize=18, textColor=DARK_BLUE, fontName="Helvetica-Bold", leading=22, alignment=TA_CENTER)),
    Paragraph("For Parents of Girls Aged 9–18 Years", sty("Q2S", fontSize=12, textColor=MID_BLUE, fontName="Helvetica", leading=16, alignment=TA_CENTER, spaceAfter=6)),
    hr(),
    box("Instructions: This questionnaire is for parents who have at least one daughter aged 9–18 years. Please answer honestly. All responses are completely confidential. Estimated time: 10–12 minutes.", BLUE_BOX, MID_BLUE),
    sp(6),
]

# Section A Parents
story += [section_header("SECTION A — Sociodemographic Information"), sp(4)]
pA = [
    ("A1", "Age: _______ years"),
    ("A2", "You are: ○ Mother  ○ Father  ○ Guardian"),
    ("A3", "Highest education level completed:"),
    ("A4", "Occupation:"),
    ("A5", "Religion: ○ Hindu  ○ Muslim  ○ Christian  ○ Jain  ○ Other: _______"),
    ("A6", "Monthly family income (approximate):"),
    ("A7", "Residence: ○ Urban  ○ Semi-urban  ○ Rural"),
    ("A8", "Number of daughters aged 9–18 years: _______"),
]
pA_opts = [
    None,
    None,
    "○ No formal education  ○ Primary (up to Cl.5)  ○ Secondary (Cl.6–10)  ○ Higher Secondary (Cl.11–12)  ○ Graduate and above",
    "○ Homemaker  ○ Farmer  ○ Business/Self-employed  ○ Salaried employee  ○ Daily wage worker  ○ Other: _______",
    None,
    "○ Below ₹10,000  ○ ₹10,000–₹25,000  ○ ₹25,001–₹50,000  ○ Above ₹50,000",
    None,
    None,
]
for i, (num, text) in enumerate(pA):
    story += q(num, text)
    if pA_opts[i]:
        story += [Paragraph("   " + pA_opts[i], Opt)]
    story += [sp(2)]

# Section B Parents Filter
story += [sp(6), section_header("SECTION B — Knowledge of HPV and Cervical Cancer", DARK_BLUE), sp(4)]
story += [
    box("⚠ FILTER QUESTION — Must be asked FIRST.", RED_BOX, colors.HexColor("#C62828")),
    sp(4),
    Paragraph("B0.  Have you ever heard of HPV (Human Papillomavirus) or the HPV vaccine for girls before this survey?", Filter),
    Paragraph("○  Yes, I have heard of it and know something about it", Opt),
    Paragraph("○  I have heard the name but I do not know what it means", Opt),
    Paragraph("○  No, I have never heard of HPV or HPV vaccination before today", Opt),
    sp(4),
    box("📋 Researcher Instruction:\n✔ If 'Yes' → Proceed to B1–B15.\n✔ If 'Heard name only' or 'No' → Read the following aloud, then SKIP to Section C:\n\n\"HPV stands for Human Papillomavirus. It is a common infection that can cause cervical cancer, which is one of the leading causes of cancer death in Indian women. The Government of India has started a free vaccination program for girls aged 9 to 14 years to prevent this disease.\"\n\nNote: Continue with Sections C, D, and E for all participants regardless of B0 answer.", GREEN_BOX, GREEN),
    sp(6),
    Paragraph("Instructions for B1–B15: Circle TRUE, FALSE, or DON'T KNOW for each statement.", Instr),
    sp(4),
]

bqs_p = [
    ("B1",  "Cervical cancer is caused by poor hygiene and has nothing to do with any infection.",           "Correct: FALSE — caused by HPV infection"),
    ("B2",  "HPV infection is very rare — most Indian women will never encounter this virus in their lifetime.", "Correct: FALSE — very common infection"),
    ("B3",  "The HPV vaccine should only be given to girls who are already showing signs of infection.",      "Correct: FALSE — given before exposure for prevention"),
    ("B4",  "A girl who receives the HPV vaccine is completely protected from all types of cervical cancer.", "Correct: FALSE — protects against most but not all types"),
    ("B5",  "The HPV vaccine has been in use globally for over 15 years and has a well-established safety record.", "Correct: TRUE"),
    ("B6",  "Girls aged 9–14 years need only 2 doses of HPV vaccine under the government program.",          "Correct: TRUE"),
    ("B7",  "The HPV vaccine is more effective if given after a girl has her first menstrual period.",        "Correct: FALSE — age, not menstruation, determines timing"),
    ("B8",  "The Government of India launched a nationwide free HPV vaccination program in 2024.",            "Correct: TRUE"),
    ("B9",  "Only girls from poor or rural families are at risk of HPV infection — educated families are safe.", "Correct: FALSE — affects all social groups"),
    ("B10", "Even after receiving the HPV vaccine, women should still get cervical cancer screening when they grow up.", "Correct: TRUE"),
    ("B11", "The HPV vaccine was introduced in India only as a family planning measure.",                     "Correct: FALSE — it is for cancer prevention"),
    ("B12", "Vaccinating a daughter against HPV is the same as encouraging her to be sexually active.",      "Correct: FALSE — this is a common misconception"),
    ("B13", "Only girls from low-income families need the HPV vaccine — it is not needed for all girls.",    "Correct: FALSE"),
    ("B14", "Cervical cancer kills approximately one woman every 8 minutes in India.",                       "Correct: TRUE"),
    ("B15", "A healthy diet, regular exercise, and prayer alone are sufficient to prevent HPV infection and cervical cancer.", "Correct: FALSE — vaccination and screening are needed"),
]
for num, text, note in bqs_p:
    story += q(num, text, note) + tf_opts() + [sp(3)]

# Section C Parents
story += [sp(6), section_header("SECTION C — Attitudes Toward Vaccinating Your Daughter"), sp(4)]
story += [Paragraph("Rate each statement from 1 (Strongly Disagree) to 5 (Strongly Agree).", Instr), sp(4)]
cqs_p = [
    ("C1",  "I would wait until my daughter is older (above 18 years) before considering the HPV vaccine for her.", "Negative — misses the recommended window"),
    ("C2",  "A vaccine linked to a sexually transmitted infection is not appropriate for young girls in our culture.", "Negative statement"),
    ("C3",  "I would rather not vaccinate my daughter than risk side effects I am not sure about.",         "Negative statement"),
    ("C4",  "I believe the government's free HPV vaccination program has good intentions for girls' health.", None),
    ("C5",  "If my doctor or ASHA worker strongly recommends the HPV vaccine for my daughter, I would follow their advice.", None),
    ("C6",  "I think discussing HPV vaccination with my daughter would be uncomfortable and unnecessary at her age.", "Negative statement"),
    ("C7",  "Protecting my daughter from cervical cancer is more important than concerns about what others in my community think.", None),
    ("C8",  "I trust what my relatives and neighbors say about vaccine risks more than what a doctor or health worker advises.", "Negative — tests source of health information"),
    ("C9",  "I would vaccinate my daughter even if other families in my community were against it.",         None),
    ("C10", "The HPV vaccine is a foreign concept that does not fit with Indian values and traditions.",     "Negative statement"),
]
for num, text, note in cqs_p:
    story += q(num, text, note) + likert_scale() + [sp(3)]

# Section D Parents
story += [sp(6), section_header("SECTION D — Perceived Barriers to Vaccinating Your Daughter"), sp(4)]
story += [Paragraph("Rate how much each factor would prevent YOU from vaccinating your daughter (1 = Not at all, 5 = Completely stops me).", Instr), sp(4)]
dqs_p = [
    ("D1",  "My husband / in-laws / family would not agree to vaccinate our daughter.",                      None),
    ("D2",  "The vaccination centre is too far from where we live.",                                         None),
    ("D3",  "I have heard from someone I personally trust that the HPV vaccine caused harm to a girl.",      None),
    ("D4",  "I am not aware of when or where the government is providing the free HPV vaccine.",             None),
    ("D5",  "I believe my daughter is still too young to need this vaccine right now.",                      None),
    ("D6",  "Arranging for vaccination feels like too much of a burden on top of other family responsibilities.", None),
    ("D7",  "I feel that talking about HPV with my daughter would be inappropriate given her age.",          None),
    ("D8",  "My trust in government vaccination programs has reduced after my experience with COVID-19 vaccines.", None),
    ("D9",  "I believe natural immunity and traditional remedies are sufficient — vaccines are not necessary.", None),
    ("D10", "I am worried my daughter's friends or community members will tease or judge her for receiving this vaccine.", None),
]
for num, text, note in dqs_p:
    story += q(num, text, note) + barrier_scale() + [sp(3)]

# Section E Parents
story += [sp(6), section_header("SECTION E — Willingness to Vaccinate Your Daughter"), sp(4)]
eqs_p = [
    ("E1", "Has your daughter already received the HPV vaccine?",
     ["○ Yes", "○ No", "○ Not sure"]),
    ("E2", "If a health worker came to your home today offering a free HPV vaccine for your eligible daughter, what would you do?",
     ["○ Allow vaccination immediately without hesitation",
      "○ Ask for more information first, then decide",
      "○ Tell them to come back another time",
      "○ Politely refuse",
      "○ Firmly refuse"]),
    ("E3", "A neighbor tells you her daughter had a high fever after HPV vaccination. What would you do?",
     ["○ Cancel your daughter's vaccination immediately",
      "○ Consult a doctor to find out if this is a normal side effect before deciding",
      "○ Ask several other people in the community before deciding",
      "○ Proceed with vaccination — minor side effects are expected with any vaccine",
      "○ Share the story on WhatsApp as a warning to other parents"]),
    ("E4", "Who has the MOST influence over your decision to vaccinate your daughter? (Choose one)",
     ["○ My own judgment",
      "○ Husband / spouse",
      "○ Parents / in-laws",
      "○ Doctor / ASHA / health worker",
      "○ Community members / neighbors",
      "○ Religious leader"]),
    ("E5", "What is your current intention regarding HPV vaccination for your daughter?",
     ["○ Will vaccinate as soon as possible",
      "○ Will vaccinate after getting more information",
      "○ Still undecided — need more time",
      "○ Unlikely to vaccinate",
      "○ Will definitely not vaccinate — Reason: _______________________"]),
]
for num, text, options in eqs_p:
    story += q(num, text) + [Paragraph(o, Opt) for o in options] + [sp(4)]

story += [
    sp(6),
    box("Scoring Guide (For Researcher):\n• Section B: TRUE=1, FALSE=0, DON'T KNOW=0. Reverse score B1, B2, B3, B4, B7, B9, B11, B12, B13, B15 (FALSE=1).\n  Poor knowledge: 0–7 | Moderate: 8–11 | Good: 12–15\n• Section C: Reverse score C1, C2, C3, C6, C8, C10 (5=1, 4=2, 3=3, 2=4, 1=5).\n  Negative attitude: 10–25 | Neutral: 26–35 | Positive: 36–50\n• Section D: Higher total score = more barriers (range 10–50)\n• Section E: Descriptive frequency analysis", GREEN_BOX, GREEN),
    sp(10),
    Paragraph("— End of Questionnaire —", sty("END", fontSize=10, textColor=colors.grey, alignment=TA_CENTER, fontName="Helvetica-Oblique")),
]

# BUILD
doc = SimpleDocTemplate(
    OUTPUT,
    pagesize=A4,
    leftMargin=1.8*cm, rightMargin=1.8*cm,
    topMargin=2.0*cm,  bottomMargin=1.8*cm,
    title="HPV KAP Questionnaires",
    author="Pharm.D 5th Year, Anand Gujarat"
)
doc.build(story, onFirstPage=page_header, onLaterPages=page_header)
print(f"SUCCESS: {OUTPUT}")