Examining Barriers and Facilitators of HPV Vaccination in Nigeria, in the Context of an Innovative Delivery Model: A Mixed-methods Study

"...study found that effective awareness is the most important factor associated with the uptake of HPV vaccination."

Human papillomavirus (HPV) has been linked to more than 90% of cases of cervical cancer, which is a leading cause of cancer deaths in women in sub-Saharan Africa. The HPV vaccine has been introduced in fewer than 27% of low-income countries. This study was designed to understand the factors that affect the actual behaviour of individuals who have been offered the HPV vaccine by examining a school-based, low-cost HPV vaccination programme administered by a private organisation in Nigeria (Prettyhealth Care).

Participants were drawn from six schools in the southwest state of Nigeria; four schools were located in Lagos state and two in Ogun state. The mixed-methods convergent study featured a case–control quantitative arm that recruited caregivers of adolescent schoolgirls as cases (those who accepted vaccination) and controls (those who did not accept vaccination). The survey was created using the PRECEDE model, a health promotion model that looks at internal and external factors influencing individuals' behaviours by exploring the predisposing, reinforcing, enabling and policy factors associated with vaccine uptake. The qualitative study involved 10 focus group discussions with caregivers and 6 in-depth interviews with school administrators, vaccination sponsors, and policymakers.

In total, 344 participants (80.9%) accepted the vaccine (cases), while the remaining 81 (19.1%) did not accept (controls). Almost half of the participants (48.4%) only heard of the HPV vaccine after enrolling their children in school. The greatest concern parents had before accepting or rejecting vaccination was safety (65.5%), followed by long-term side effects (21.1%) and cost (6.3%). The study identified two main facilitators to HPV vaccination uptake: convenience and awareness. A key barrier to uptake is lack of accessibility, which comprises lack of affordability and lack of availability of the HPV vaccine. As reported here, school-based programmes that offer HPV vaccinations free of charge or through a subsidised, need-based copayment system stand to overcome many structural barriers to HPV vaccination.

Those with high awareness of HPV vaccination had three times the odds of uptake (adjusted OR (aOR) 2.6, 95% confidence interval (CI) 1.54 to 4.31, p=0.002). Giving HPV vaccines in school was also associated with uptake (aOR 3.1, 95% CI 1.54 to 6.43, p=0.002). Being offered free HPV vaccination was significant in the bivariate analysis (aOR 1.67, 95% CI 1.03 to 2.70, p=0.039) but was marginally significant in the multivariate analysis (aOR 0.63, 95% CI 0.37 to 1.06, p=0.086).

Qualitative themes supported these findings, demonstrating that effective awareness and convenience of vaccination could encourage uptake. For example, the study respondents explained:

• They were inclined to agree to vaccination when vaccine information came from a trusted source, such as a doctor or nurse (though credible sources could exist outside the medical profession as well).
• To be effective, awareness must be tailored to the environment. School was considered by participants to be a good place to receive information about vaccines for adolescents, though they acknowledge that this school-based approach may not be applicable to regions of the country where there are many out-of-school children.
• They were more likely to accept vaccination when they saw other parents vaccinating their children at the same time.
• The ability to express their concerns, seek clarifications, and receive vetted information in two-way discussions with knowledgeable individuals made it more likely they would accept vaccination.
• In order to avoid misunderstandings or negative information, it is important for awareness campaigns to deliver communication about the HPV vaccine that is clear, unambiguous, and thorough.

In conclusion, this study emphasises that, in order for awareness of the vaccine to truly affect uptake, it must come from trusted sources and be delivered in a trusted environment. In addition to effective awareness-raising, administering HPV vaccines in school and subsidising HPV vaccination costs can improve uptake.