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Health services research
Original research
Factors associated with uptake of human papillomavirus vaccination among adolescent girls in Mettu town, southwest Ethiopia: a school-based cross-sectional study
  1. Amin Dawud1,
  2. Abeza Mitiku Kera2,
  3. Desta Bekele3,
  4. Desta Hiko3,
  5. Asrat Zewdie2
  1. 1Mettu Woreda Health Office, Mettu, Ethiopia
  2. 2Department of Public Health, Mattu University, Mettu, Ethiopia
  3. 3Department of Epidemiology and Biostatistics, Jimma University, Jimma, Ethiopia
  1. Correspondence to Abeza Mitiku Kera; abzmtk{at}gmail.com

Abstract

Objective This study was designed to assess the level of uptake of human papillomavirus (HPV) vaccination and its associated factors among school-age adolescent girls.

Design School-based cross-sectional study.

Setting High schools in Mettu town, southwest Ethiopia, from 5 February to 10 March 2022.

Participants Data were collected using a pretested and structured questionnaire through face-to-face interviews with 667 adolescent girls selected via multistage random sampling. Data were entered into EpiData V.3.1 and exported to SPSS V.26 for analysis. Simple binary logistic regression was done, and variables with a p value less than 0.25 were entered into a multivariable logistic regression model; variables with a p value <0.05 were considered significant.

Results About half (48.6%) of adolescent girls aged 14–18 years had received the HPV vaccine. Being in the 16–18 years age group (adjusted OR 2.7, 95% CI 1.50 to 4.80), having good knowledge (2.14, 95% CI 1.29 to 3.52), having a positive attitude (5.86, 95% CI 3.51 to 9.76), and getting encouragement from healthcare workers (3.04, 95% CI 1.36 to 6.79), teachers (2.14, 95% CI 1.05 to 4.34) and parents (2.39, 95% CI 1.02 to 5.64) were significantly associated with vaccine uptake.

Conclusion The uptake of HPV vaccination was low. Having good knowledge and positive attitude as well as encouragement from parents, healthcare workers and teachers were identified as factors associated with HPV vaccine uptake. Improving knowledge about HPV and involving teachers and parents in the immunisation campaign might help promote HPV vaccine uptake.

  • public health
  • hypertension
  • endocrine tumours
  • nutritional support
  • malabsorption

Data availability statement

Data are available upon reasonable request. All data relevant to the study are included in the article or uploaded as supplementary information.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi-org.ezproxy.u-pec.fr/10.1136/bmjopen-2023-071878

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    STRENGTHS AND LIMITATIONS OF THIS STUDY

    • This study used a stratified multistage random sampling method and had a high response rate.

    • The school-based nature of the study might not reflect the actual uptake of human papillomavirus vaccination among adolescent girls at the community level.

    • Qualitative data were not used to support the findings.

    Introduction

    Human papillomavirus (HPV) is a family of more than 170 viruses, 15 of which are classified as high-risk HPV types and are linked to the development of HPV-related cancers. Persistent HPV infection can lead to the development of precancerous lesions of the cervix, with 99% of cervical cancers being attributable to HPV infection. In addition to cervical cancer, the high-risk strains of HPV can also contribute to other forms of cancer, such as cancer of the vulva, vagina, anus, penis, and head and neck.1 2

    HPV types 6 and 11 are responsible for 90% of genital warts, while types 16 and 18 are considered to contribute to 70% of cases of cervical cancer; types 16 and 18, respectively, represent 45.3% and 8.2% of cases in Ethiopia.3 4 HPV infects approximately 75% of sexually active men and women during their lifetime.3 Multiple sexual partners, early marriage, younger age at first sexual intercourse, poor dietary habits, cigarette smoking and immune suppression are all risk factors for HPV infection and progression.1 2 5

    About 99% of cervical cancers are related to HPV infection.4 It is the most common type of cancer that arises from the cervical area .6 Early stages might be asymptomatic, but advanced stages can show symptoms such as unexplained weight loss, persistent pelvic pain, unusual bleeding periods, and pain and bleeding after sexual intercourse.7 8

    Globally, 500 000 women are affected by cervical cancer every year. In 2012, there were 14.1 million new cancer cases and 8.2 million cancer deaths worldwide, with 57% of cases and 65% of deaths occurring in lower-income countries.9 The disease burden of cervical cancer in Africa is estimated at nearly 79 000 new cases each year. The risk of dying from cervical cancer before the age of 75 is three times higher in low-income countries than in more developed countries, and cervical cancer mortality remains high among African women.8 10

    In Ethiopia, cervical cancer ranks as the second cause of cancer death, next to breast cancer, and is common among women aged 35–44 years old.11 More than 4648 women are diagnosed with cervical cancer each year, among them 3235 die annually.6 An estimated 33.6% of Ethiopian women will be infected by HPV, which is vaccine-preventable, at some point in their life.12 About 4.7% of women in the general population are estimated to harbour cervical HPV 16/18 infection at a given time, and 67.9% of invasive cervical cancers are attributed to HPV 16 or 18.6

    HPV vaccination is the most commonly used public health strategy to reduce the risk and prevalence of the disease caused by HPV.13–15 According to the American Cancer Society guidelines, HPV vaccination should start at the age of 9 years and be recommended through age 26. The effectiveness of HPV vaccination is high if routinely administered at the age of 9–12 years.16

    Although Ethiopia has been running a cervical cancer screening programme, only 14.79% of eligible women have been screened.17 Ethiopia began HPV vaccination in 2018, which was delivered through a school-based approach to 14-year-old female students in two-dose schedules over 6 months, as per the WHO guidelines.18

    In Ethiopia, the uptake of HPV vaccination among female students is 44.4% in Ambo, 66.5% in Minjar Shenkora in North Shoa, 50.4% in Arba Minch and 45.3% in Bahir Dar City.19–22 There is a gap in achieving the global HPV vaccination target coverage of vaccinating 90% of female adolescents by the age of 15 years in order to eliminate cervical cancer by 2030.23

    However, there is limited evidence regarding the uptake of human papilloma virus vaccination in southwest Ethiopia, particularly in Mettu town apart from some reports generated by local health authorities.Therefore, this study aimed to assess the uptake of human papillomavirus vaccination and its associated factors among school-age adolescent girls in Mettu town, which may help stakeholders in developing strategies that improve the uptake of the HPV vaccine nationally

    Methods

    Study design, setting and population

    A school-based cross-sectional study was conducted from 5 February to 10 March 2022 in Mettu town, which is located 606 km from the capital city of Ethiopia, Addis Ababa, in the southwest direction. The estimated total population in 2021 was 46 810, of whom 23 786 (50.8%) were male and 23 024 (49.2%) were female, as projected from the 2007 census. It has three public secondary schools, seven public primary schools and three private primary schools, with a total of 7582 students, of whom 4082 (54%) were female and 3500 (46%) were male.

    All school-age adolescent girls within the age interval of 14–18 years attending grades 5–12 in the 2021–2022 academic year were the source population from which the study sample was randomly selected.

    Eligibility criteria

    School-age adolescent girls aged 14–18 who were currently attending education at public or private schools in Mettu town from grades 5 to 12 were included in the study. School-age adolescent girls with developmental challenges who could not give consent were excluded.

    Sample size and sampling procedures

    The sample size was determined using a single population proportion formula by considering a 95% CI with 0.03 margin of error and taking the proportion of HPV vaccine utilisation of 17.6% from a previous study.24 The initial sample size was 619. By adding a 10% non-response rate, the final sample size was 681.

    The study covered 10 primary and 3 secondary schools found in Mettu town. The list of adolescent girls aged 14–18 was obtained from the respective school directors and then combined into a single data set for each school. The data set included students’ information such as name, age, grade level and section. The required number of participants selected from each school was determined based on a proportional population size allocation. Finally, through a simple random sampling technique, 681 students were selected using the OpenEPI random number computer generator.

    Data collection tools and procedures

    Data were collected using a structured and pretested questionnaire adapted from previous similar studies.25–28 The questionnaire had four parts: sociodemographic and economic information; knowledge of cervical cancer, HPV and its vaccine; attitude towards HPV vaccine; and uptake of HPV vaccination and related characteristics (online supplemental file 1).

    Overall knowledge of cervical cancer, HPV and its vaccination was measured using 18 dichotomous yes/no variables (6 knowledge statements about cervical cancer, 6 knowledge statements about HPV infection and 6 knowledge statements about HPV vaccination). During analysis, a correct answer was coded as 1, while an incorrect answer was coded as 0. Attitude towards HPV vaccination was measured by five items on a Likert scale. Using the mean score, attitude was categorised into positive and negative attitudes.

    The questionnaire was first prepared in English and then translated to Afan Oromo and then back to English to check for consistency by an expert who had good ability in both languages. Data were collected by eight diploma-holder teachers, and two professional nurses were recruited as supervisors during data collection. Data were gathered through a school-to-school visit of adolescent girls in their classes. If eligible students were absent during the data collection period, revisit to their classes was done three times, and adolescent girls who were absent on the third visit were considered non-respondents.

    Data quality control

    Before data collection, the questionnaire was pretested on a 5% sample size in other schools which were not part of the actual data collection area. Based on the pretest, some modifications such as unclear or vague questions and wrong skip patterns were corrected. Two days of training were given by the principal investigator to data collectors and supervisors on data collection tools, data collection techniques, approach to interviews, and maintaining respondents’ privacy and confidentiality. The internal consistency of the items used to measure attitude was checked using Cronbach’s alpha test (alpha value=0.89). Every day after data collection, the questionnaires were reviewed by the supervisors and the principal investigator and were checked for completeness. The questionnaires were reviewed and checked for completeness, word errors, unclear questions and consistency by the supervisors and the principal investigator, and necessary feedback was given to data collectors each morning.

    Operational definitions

    HPV vaccine uptake

    HPV vaccine uptake is defined by the proportion of eligible female adolescent students who received at least one dose of the HPV vaccine.

    Knowledge

    Respondents who scored greater than or equal to the mean score of the knowledge questions were categorised as having good knowledge, whereas those who scored less than the mean score were categorised as having poor knowledge.

    Attitude

    The respondents who scored greater than or equal to the mean score on attitude-related questions were classified as having a positive attitude, while participants who scored less than the mean score were classified as having a negative attitude.

    Data processing and analysis

    Data were entered into EpiData V.3.1 and exported to SPSS V.26 for analysis. Descriptive analysis was done using frequency, proportion and other summary statistics, and the results were presented in the form of a table, graph and narrative summary. Simple binary logistic regression analysis was done to identify candidates for the multivariable logistic regression model, and variables with a p value less than 0.25 were entered into the multivariable logistic regression model.

    Pseudo-regression was performed to check for multicollinearity between independent variables; the minimum tolerance and maximum variance inflation factors were found to be 0.73 and 1.94, respectively. The model’s goodness of fit was also checked using the Hosmer and Lemeshow model of test of fitness (p=0.92). The findings from multivariable regression were presented using adjusted OR (AOR), along with the corresponding 95% CI. Variables with a p value <0.05 were declared statistically significant.

    Patient and public involvement

    There was no patient and public involvement.

    Results

    Sociodemographic characteristics of the participants

    A total of 667 school-age adolescent girls participated in the study, with a 97.9% response rate. The median age of the respondents was 16 years, with a minimum and maximum age of 14 and 18 years, respectively. Of the respondents, 502 (75.3%) were attending secondary school and 589 (88.3%) were urban residents. Regarding family income per month, 385 (57.7%) earn less than 2000 Ethiopian birr (table 1).

    View this table:
    Table 1

    Sociodemographic characteristics of the study participants (N=667)

    Knowledge of cervical cancer, HPV infection and HPV vaccination

    Of the 667 participants, 591 (88.6%) had heard about cervical cancer and 401 (67.9%) knew that all women are at risk of cervical cancer. Regarding HPV infection, 574 (86.1%) ever heard about HPV infection, 267 (46.5%) knew that HPV causes cervical cancer, 566 (84.9%) knew that HPV infection has a vaccine and 417 (73.7%) knew that the vaccine can effectively prevent cervical cancer (table 2).

    View this table:
    Table 2

    Knowledge about cervical cancer, HPV infection and HPV vaccination among school adolescent girls in Mettu town, southwest Ethiopia, 2022

    The study participants’ overall mean score (SD) on knowledge was 11.11±3.22. Of the study participants, 293 (49.6%) had good knowledge of cervical cancer, HPV and its vaccination.

    Source of information on HPV

    Of the study participants, 574 (86.1%) had heard about HPV, of whom 279 (48.6%) had heard it from healthcare workers, 171 (29.8%) from mass media, and 13.6%, 4.2% and 3.8% had heard it from their teachers, parents and friends, respectively.

    Attitude towards HPV vaccination

    Among the study participants, 202 (30.3%) agreed that they are at risk of HPV infection and would like to be vaccinated, 242 (36.3%) agreed on the severity of HPV infection, and 252 (37.8%) agreed that the vaccine would keep them safe and healthy. The mean (SD) score on attitude was 3.70±0.94. Of these, 388 (58.2%) had a positive attitude towards vaccination (table 3).

    View this table:
    Table 3

    Attitude towards HPV vaccination among school adolescent girls in Mettu town, southwest Ethiopia, 2022

    Uptake of HPV vaccination

    The uptake of HPV vaccination among female adolescent students was 324 (48.6%) (95% CI 45.3 to 52), of whom 183 (56.5%) received one dose and 141 (43.5%) received two doses. More than half (51.4%) of the respondents did not receive the vaccination. The most common reasons for not getting vaccinated against HPV infection were not being informed by the healthcare worker during the vaccination (28.9%) and unavailability of sufficient vaccine on their visit (23.9%). Other reasons such as the belief that they are not sexually active, belief that there is no need for vaccine, fear of side effects and fear of needle account for 15.7%, 14.6%, 11.10% and 5.8%, respectively.

    Factors associated with uptake of HPV vaccination

    In the multivariable analysis, the age of the participants (AOR=2.7, 95% CI 1.50 to 4.80), knowledge about cervical cancer, HPV infection and its vaccination (AOR=2.14, 95% CI 1.29 to 3.52), attitude towards HPV vaccination (AOR=5.86, 95% CI 3.51 to 9.76), and vaccine encouragement by healthcare workers (AOR=3.04, 95% CI 1.36 to 6.79), teachers (AOR=2.14, 95% CI 1.05 to 4.34) and parents (AOR=2.39, 95% CI 1.02 to 5.64) were significantly associated with uptake of HPV vaccination (table 4).

    View this table:
    Table 4

    Multivariable analysis of factors associated with uptake of HPV vaccination among school adolescent girls in Mettu town, southwest Ethiopia, 2022

    Discussion

    The HPV vaccine is one of the main preventive measures for cervical cancer. Hence, this study aimed to assess the uptake of HPV vaccination and its associated factors among school-age girls. Accordingly, the uptake of HPV vaccination among the study participants was 48.6% (95% CI 45.3 to 52). Being in the 16–18 years age group, having good knowledge, having a positive attitude, and getting encouragement from healthcare workers, teachers and parents were significantly associated with uptake of vaccination.

    The uptake of HPV vaccination in this study was consistent with other studies conducted in Ethiopia, such as in Arba Minch (50.4%)20 and Bahir Dar (45.3%),19 whereas it is relatively higher compared with studies conducted in Debre Berhan in Northern Ethiopia (41.7%),29 Ambo in West Ethiopia (44.4%)21 and in Uganda (42.4%).30

    The uptake of vaccination in our study area is relatively lower compared with the findings of the study conducted in North Shoa, Ethiopia (66.5%),22 Zambia (53.8%),30 Hong Kong, China (81.4%),31 and Victoria, Australia (81%), and in studies conducted in South Africa and Negeri Sembilan, which reported 75% and 89.8% of the participants had received at least one dose of the HPV vaccine.32 33 The disparity could be due to differences in sociodemographic characteristics and study period among the study participants.

    On the other hand, our findings are much higher than the findings of the studies conducted in Benin City in Nigeria (0.5%), Lebanon (2.5%), Uganda (14%) and Ibadan in Nigeria (4.1%).26 34–36 The disparity could be attributed to differences in the study period, presence of reproductive health information at schools, and sociodemographic backgrounds such as religion and culture.

    In this study, half (49.6%) of the participants had good knowledge of cervical cancer and HPV, which is significantly associated with HPV vaccine utilisation. This finding is consistent with findings from other studies conducted in Bahir Dar, Ethiopia (45.3%),19 India (44%),37 Indonesia (44.4%)28 and Malaysia (50.8%),33 whereas it is relatively lower compared with studies conducted in Ambo (88.6%),21 Debre Markos (59.2%)29 and Arba Minch in Ethiopia (75.2%),20 as well as in Italy (56.3%).38 The discrepancy might be attributed to differences in the accessibility of information on reproductive health and study areas.

    In this study, the age of the participants was associated with the uptake of HPV vaccination. School-age girls in the 16–18 years age group were 2.7 times more likely to receive the HPV vaccine compared with those in the 14–15 years age group. This finding is in line with a study conducted in Germany.39 The possible explanation might be that, as age increases, the ability and interest in new information increase, which contributes to their health. In addition, the majority of these age groups were attending secondary school. As a result, they could gain more information on HPV infection and vaccination.

    Participants who had good knowledge of cervical cancer, HPV infection and vaccination were 2.14 times more likely to receive the HPV vaccine than those who had poor knowledge. This finding is agreement with other studies conducted in Ethiopia, such as in North Shoa,22 Debre Tabor,29 Arba Minch20 and Bahir Dar.19 This can be explained by the fact that adolescents with good knowledge were adequately informed about the advantages of receiving the HPV vaccine. This finding is more supported by the study conducted in Harar, Ethiopia, which depicted that adolescents who had good knowledge of reproductive health services were 2.8 times more likely to use them.40

    In this study, participants who had a positive attitude towards vaccination were 5.86 times more likely to receive the HPV vaccine when compared with participants who had a negative attitude towards vaccination. This finding agrees with the findings of the study conducted in Uganda,24 Ambo in Ethiopia21 and Arba Minch.20 This might be the result of their internal perceptions of the seriousness of HPV infection and the potential benefits of the vaccine in terms of protecting them from the infection and maintaining their health, which could have inspired them to receive the vaccination. This finding is also supported by the study conducted in Ari District, South Omo Zone, Ethiopia, where adolescents with a positive attitude towards reproductive health were five times more likely to use reproductive health services.41

    Furthermore, students who were encouraged by healthcare workers, teachers and parents were more likely to get the HPV vaccine compared with those who were encouraged by their friends. This finding is consistent with the study conducted in the Lira district of Uganda.24 Our findings are supported by other studies conducted in rural districts of Uganda42 and in Victoria, Australia,43 which showed that encouragement of students by their teachers, healthcare workers and parents enhances the uptake of HPV vaccination. This could be because students believe that healthcare workers, teachers and parents are reliable sources of health information, .leading them to a decision to receive the vaccination.44 As part of the major national strategic initiative to strengthen the integration of adolescents’ health with school health initiatives and programmes in the Second Health Sector Transformation Plan,45 HPV vaccination among adolescent girls in Ethiopia is given priority to combat transmission, mortality and morbidity associated with cervical cancer. In this manner, the findings in this study will be a significant input for policymakers to understand coverage by region and expand the service by designing interventions based on the identified factors. The limitation is that the generalisability of the study to a population of the same age in the community is limited since this was an institutional-based study.

    Conclusion

    According to the current study, the uptake of HPV vaccination among school-age girls was low. Being in the 16–18 years age group, having good knowledge, having a positive attitude, and getting encouragement from healthcare workers, teachers and parents were significantly associated with uptake of vaccination. Therefore, health education should be provided through all possible means. Teachers and parents of students should take part in the vaccination campaign, in addition to healthcare workers, in order to enhance the uptake of vaccination.

    Data availability statement

    Data are available upon reasonable request. All data relevant to the study are included in the article or uploaded as supplementary information.

    Ethics statements

    Patient consent for publication

    Ethics approval

    Ethical clearance was obtained from the institutional review board of Jimma University, Institute of Health (ref no: IHRB 28 /21), submitted to Mettu town education office. A letter of permission was obtained from Mettu town education office. The nature of the study was fully explained to the study participants and their parents/guardians. Informed verbal and written consent was obtained from the parents/guardians of participants younger than 18 years, and assent was obtained from the participants before the interview.

    Acknowledgments

    We would like to acknowledge Jimma University, the Department of Epidemiology and Biostatistics, and the Mettu town education and health offices and teachers for their support throughout the study period. We are also grateful to the data collectors, supervisors and study participants for their valuable contributions.

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    Supplementary materials

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    Footnotes

    • Twitter @Asrat Zewdie

    • Contributors AD developed the research idea, design and analysis, and drafted the manuscript. AMK, DB, DH and AZ conceived the study, supervised the data collectors, interpreted the results and reviewed the manuscript. All authors read and approved the final manuscript. AD is responsible for the overall content as guarantor.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.