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Global health
Original research
Female adolescents’ knowledge and acceptability of human papillomavirus vaccine in Debre Tabor Town, Ethiopia: a cross-sectional study
  1. Gedefaye Nibret Mihretie1,
  2. Tewachew Muche Liyeh1,
  3. Alemu Degu Ayele1,
  4. Habtamu Gebrehana Belay1,
  5. Tigist Seid Yimer1,
  6. Agernesh Dereje Miskr1,
  7. Bekalu Getnet Kassa1,
  8. Adanech Getie Tefera1,
  9. Enyew Dagnaw1,
  10. Yismaw Yimam Belachew2,
  11. Gebrehiwot Ayalew Tiruneh1,
  12. Worku Necho Asferi3,
  13. Sisay Getu4,
  14. Tigabu Munye Aytenew5
  1. 1Department of Midwifery, Debre Tabor University, Debre Tabor, Amhara, Ethiopia
  2. 2Obstetric and Gynecology, Debre Tabor University, Debre Tabor, Amhara, Ethiopia
  3. 3Neonatal Nursing and Child Health, Debre Tabor University, Debre Tabor, Amhara, Ethiopia
  4. 4Medical Laboratory, Debre Tabor University, Debre Tabor, Amhara, Ethiopia
  5. 5Nursing, Debre Tabor University, Debre Tabor, Amhara, Ethiopia
  1. Correspondence to Mr Gedefaye Nibret Mihretie; gedefayen{at}gmail.com

Abstract

Objective This study aimed to assess the knowledge and acceptability of the human papillomavirus (HPV) vaccine and associated factors among female adolescent students in Debre Tabor Town, Ethiopia, 2021.

Design Cross-sectional study was done from 9 December 2020 to 28 February 2021.

Analysis The data were entered into EpiData V.4.2 and analysed with SPSS V.23 software. The OR, 95% CI and p<0.05 were used to determine the bivariable and multivariable statistical association.

Setting Three high schools (grades 9 and 10) and six primary schools (grades 7 and 8) were included in the study.

Participants Adolescent female students in Debre Tabor Town.

Results The overall knowledge score in the questionnaire was six, and it was divided into two groups based on scoring level: poor (score <3) and good (score ≥3). More than half respondents (59.2%) scored good knowledge. The proportion of acceptability of the HPV vaccine was 61.9%. Age (adjusted OR, AOR 1.70, 95% CI 1.17 to 3.88), and having a source of information (AOR 1.94, 95% CI 1.06 to 3.22) were significantly associated with the knowledge of the HPV vaccine. Place of birth (AOR 1.55, 95% CI 1.15 to 1.95), fathers’ educational status (AOR 2.80, 95% CI 1.18 to 5.65), having a source of information (AOR 2.14, 95% CI 1.05 to 4.32) and knowledge about the HPV vaccine (AOR 6.41, 95% CI 3.45 to 11.90) were significantly associated with the acceptance of the female adolescent HPV vaccine.

Conclusion In this study, the knowledge and acceptability of students of the HPV vaccine were low. Health authorities, through the mass media, should strengthen HPV vaccine promotion in schools, religious institutions and health facilities.

  • Reproductive medicine
  • Gynaecological oncology
  • Public health
  • Maternal medicine
  • GENERAL MEDICINE (see Internal Medicine)

Data availability statement

All data relevant to the study are included in the article or uploaded as online supplemental 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/.

http://dx.doi.org/10.1136/bmjopen-2022-061813

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    STRENGTHS AND LIMITATIONS OF THIS STUDY

    • The results were more representative because the data was primary.

    • This study mainly on a quantitative approach, which could not address the ‘why’ questions in detail.

    • In this study, the participants were only female students.

    Introduction

    Cervical cancer is caused by the human papillomavirus (HPV) infection. More than 100 HPV types have been identified to date, about 40 of which can infect the genital area. The two high-risk types of HPV, types 16 and 18, account for about 70% of all cervical cancer cases. HPV can also cause other types of anogenital cancers (vagina, vulva, anus, penis), head and neck cancers, and genital warts in both men and women.1 Cervical cancer is the world’s fourth most common cancer in women, following breast cancer, colorectal cancer and lung cancer, accounting for 570 000 cases and 311 000 deaths.2 In Africa, the majority of cervical cancer researchers have concentrated on secondary prevention (cervical screening), with only about 23.4% focusing on primary prevention, specifically HPV vaccination.3

    Ethiopia has a population of 29.43 million women aged 15 and above, all of whom are at risk of cervical cancer. Early sexual activity, several sexual partners and a history of sexually transmitted illnesses are the main causes of cancer-related death among Ethiopian women over the age of 30.4 In Ethiopia, it has been estimated that about 7000 cases and 5000 deaths occur every year due to cervical cancer, and it is the second-leading cause of female cancer.5 Even though 20 million Ethiopian women were eligible for cervical screening, less than 1% of them were screened.6

    Until recently, cytology-based screening programmes were the main tool to detect and treat precancerous abnormalities and the early stages of cancer, preventing up to 80% of cervical cancers in developed countries. Effective screening programmes, on the other hand, have been difficult to implement in low-resource settings, with the main obstacles being poverty and a lack of healthcare infrastructure, client embarrassment about cytology tests and a lack of trained practitioners.7 To prevent women from illness and deaths related to cervical cancer, HPV immunisation is a better option than cytology screening, particularly in resource-limited countries.8

    The two (bivalent and quadrivalent) vaccines are highly efficacious in preventing infection of types 16 and 18 viruses. The quadrivalent vaccine is also highly efficacious in preventing anogenital warts, which are caused by infection with HPV types 6 and 11. Currently, cervical cancer prevention remains the priority for HPV vaccination. The WHO recommends that girls aged 9–14 years be the primary target population for HPV vaccination, with females aged greater than 15 years and males as secondary populations.9 Ethiopia is one of only a few African countries that launched the HPV vaccine in December 2018. The vaccine is primarily delivered through a school-based approach to reach all eligible girls in both private and public schools in all regions of the country.10 Ethiopia is undergoing HPV vaccine implementation through the routine immunisation programme for adolescent girls.10 But there was not enough data that documented the encountered problems, the receiver’s knowledge and the acceptance of the HPV vaccine.11

    Vaccination against HPV infection (9–45 years of age) was 39.7% among women worldwide, with the highest rates in high-income countries (68%), middle-income countries (28%) and lower-middle-income countries (2.7%).12 Studies revealed that in Asia (77%), China (71.1%) and Kenya (40.9%), respectively.13–15

    The knowledge of the HPV vaccine was 52.7% in Hong Kong, 44% in Uganda, 21% in Southwest Nigeria and 43.8% in Southwest Ethiopia.16–19 The acceptance of the HPV vaccine in Nigeria was about 40%; Jima University medical students (36.8%); Saudi Arabia (48.9%) and Morocco (27%) of the participants were willing to get the HPV vaccine, respectively.20–23

    Gender and educational level,20 parents’ educational level(secondary and above),14 parents’ occupation (health professional),19 24 participants’ family members had a history of cervical cancer, participants who had information about the HPV vaccine (from school, newspaper and internet),24 and fear of future HPV infection14 were determinant factors of knowledge about the HPV vaccine. Participants’ educational level, information about screening (individuals heard about Pap test),14 parents’ interest in HPV vaccination,25 adolescents' educational level, mother’s educational level, parent occupation26 and participants who perceived the effectiveness of the HPV vaccine to prevent cervical cancer,26 participants who had good knowledge about HPV19 25 26 were determinant factors of HPV vaccine acceptability.

    Although HPV vaccine knowledge and acceptance are recognised as key factors in promoting HPV vaccine uptake, there is a lack of studies in our country, particularly among adolescents. The objective of this study was to assess adolescent school students’ knowledge and acceptance of the HPV vaccine and its associated factors. The study provided input for planning, designing and implementing a strategy for HPV immunisation for female adolescents, and it will serve as baseline evidence for further investigation.

    Methods

    Study setting and study period

    An institution-based cross-sectional study was conducted in Debre Tabor Town from 9 December 2020 to 28 February 2021. The town is located 665 km from Addis Ababa (the capital city of Ethiopia). The town is divided into six small administrative units called kebeles with a total population of 96 973 people, of whom 49 753 were men and 47 220 women, based on the population projection of Ethiopia for all regions at the Wereda level in 2017.27 The town had one general hospital, three health centres, six primary schools and three high schools. There were 3093 total female students in high school and primary school (grades 7 and 8). All adolescent girls who attained grades 7–10 as regular students in Debre Tabor Town during the study period were included.

    Patient and public involvement

    None.

    Sample size determination

    The Epi Info V.7 statistical software was used to calculate the sample size for objective one proportion of knowledge at 43.8% and objective two proportion of acceptance at 36.8% Jimma (36.8%).19 A precision of 5% and a CI of 95% were considered. With a design effect of 2 and a 10% non-response rate, the sample sizes were the proportion of HPV vaccine knowledge (sample size, 832) and the proportion of HPV vaccine acceptance (sample size, 786). Finally, we used the largest calculated sample size (sample size, 832).

    Sampling procedure

    The town has six primary schools and three public high schools. First stratified into two strata (three high schools, grades 9 and 10, and six primary schools, grades 7 and 8). Then, a sample frame was prepared from all schools to identify girls who fulfil the inclusion criteria by having registered names and birthdates from schools’ roster books. Then, using proportional allocation and simple random sampling procedures, 366 high school students and 466 primary school students were chosen (figure 1). For participants who were not present at the time of data collection, three revisits were made to interview the participants.

    Figure 1
    Figure 1

    The sampling procedure of the human papillomavirus vaccine among female adolescent students in Debre Tabor Town, 2021.

    Variables of the study

    Dependent variable: Knowledge and Acceptance of HPV vaccine.

    Independent variable: Sociodemographic variables (age, religion, grade level, marital status, parents’ educational status, parents’ occupation); Reproductive health-related factors (family history of cervical cancer, fear of HPV infection in the future); sources of information: knowledge of the HPV vaccine, knowledge of HPV infection and cervical cancer, and attitude towards the HPV vaccine.

    Operational definitions

    Knowledge of HPV vaccine: adolescents’ level of knowledge was measured based on correct responses using HPV vaccine knowledge questions. Each correct (yes=1) and incorrect response (no and I do not know=0) scores points, respectively. Using the mean knowledge score as the cut-off point, women’s knowledge was divided into two categories: good knowledge (scored above or equal to the mean score) and poor knowledge (scored less than the mean score of knowledge questions).28 Acceptability was considered to be participants’ mean and above the mean from acceptance items.26 Positive attitude: considered to be the participants’ mean and above the mean from the attitude question, adolescents, respondents whose age is 10–19 years old.

    Data collection procedure and techniques

    The data were collected by using pretested and structured face-to-face interviewer-administered questionnaires. The questionnaire was first developed in English and then translated to the local language (Amharic) and then back to English to keep its consistency. B.Sc. nurses who were familiar with the local language and customs were recruited as data collectors. Two-MSc midwives were assigned as supervisors. Training was given to data collectors and supervisors for 2 days on data collection procedures, the content of the questionnaire, interview techniques and confidentiality of the information obtained from the respondents.

    Data quality assurance

    Data quality was ensured during collection, entry and analysis. Before conducting the main study, a pretest was carried out on 40 (5%) of the sample. The principal investigator and supervisor conducted day-to-day on-site supervision during the whole period of data collection. At the end of each day, the questionnaires were reviewed and checked for completeness and accuracy. Two data clerks were recruited for the data entry process. The internal consistency was checked with reliability tests (Cronbach’s alpha) on the knowledge, attitude and acceptance items. Cronbach’s alpha was 0.806 for acceptability, 0.840 for knowledge and 0.922 for attitude.

    Data processing and analysis

    The data was cleaned, coded and entered into EpiData V.4.2 before being analysed with SPSS V.23. Text, figures and tables were used to present descriptive data. Binary logistic regression analysis was executed by computing the OR with a 95% CI to see the crude association between each independent and dependent variable. Finally, all independent variables associated with the dependent variable with p≤0.2 were entered into multivariable logistic regression for further analysis, and a significant association was identified based on p<0.05 and adjusted OR (AOR) with 95% CI.

    Results

    Socioeconomic characteristics of participants

    A total of 824 female adolescent students were interviewed, with a 99.0% response rate. The mean age of the respondents was 15.2 (SD±1.34). Four hundred and seventy-five (57.0%) participants were in the age group 13–15. The majority of participants were not married (97.1%). The majority of study participants, 812 (97.0%), are Orthodox Christian religious followers (table 1).

    View this table:
    Table 1

    Sociodemographic characteristics of human papillomavirus vaccine among female adolescents in Debre Tabor Town, 2021

    Reproductive-related characteristics

    Most of the study participants had no family/relative history of cervical cancer 816 (99.0%). The majority of participants had fear of sexually transmitted infections. Of those, 584 (70.9%) and 122 (14.8%) participants had a history of the sexually transmitted disease (table 2).

    View this table:
    Table 2

    Reproductive health characteristics of school female adolescents in Debre Tabor Town, 2021

    HPV vaccine utilisation and reasons for did not take HPV vaccine

    The participant vaccinated fully or partially was 65.8%. Only 41.8% of participants were fully vaccinated (two doses) (figure 2). However, many students were not vaccinated for different reasons (figure 3).

    Figure 2
    Figure 2

    Utilisation of the human papillomavirus vaccine among female adolescent students in Debre Tabor Town, 2021(n=824).

    Figure 3
    Figure 3

    The reasons for not taking the human papillomavirus vaccine among female adolescent students in Debre Tabor Town, 2021 (n=480).

    Sources of information about the HPV vaccine

    Nearly one-third of participants 256 (31.10%) had no information about the HPV vaccine. The majority of the participants heard about the HPV vaccine 568 (68.9%). Radio/television 284 (34.5%), health extension workers 212 (25.7%) and school peers 72 (8.70%) were the sources of information.

    Attitude towards cervical cancer prevention and HPV vaccine

    Five hundred and forty-two (65.8%) participants agree or strongly agree with HPV vaccination to prevent cervical cancer. Sixty per cent of participants strongly agreed with the effectiveness of the HPV vaccine (table 3).

    View this table:
    Table 3

    Attitude towards cervical cancer prevention and human papillomavirus (HPV) vaccine among female adolescents in Debre Tabor Town, 2021

    Participants’ knowledge of the HPV vaccine and cervical cancer prevention

    Three hundred and thirty-three (40.4%) of participants had poor knowledge (below the mean score, 50%) about the HPV vaccine and cervical cancer prevention, whereas 488 (59.2%) of them had good knowledge. Three hundred and twenty-eight (39.8%) of students did not know the vaccine is given before first sexual intercourse (table 4).

    View this table:
    Table 4

    knowledge of human papillomavirus vaccine (HPV) and cervical cancer among female adolescents in Debre Tabor Town, 2021

    Acceptance of HPV vaccine among female adolescents

    Approximately one-third of participants 314 (38.1%) had poor acceptability, whereas two-thirds of students 510 (61.9%) had good acceptability (table 5).

    View this table:
    Table 5

    Acceptance of human papillomavirus (HPV) vaccine among female adolescents in Debre Tabor Town, 2021

    Factors associated with knowledge of HPV vaccine and HPV vaccine

    Two models were fitted to assess the knowledge and acceptability of the HPV vaccine. The first model was fitted to assess the knowledge of the HPV vaccine. In binary logistic regression, variables such as age, place of birth, grade level, fathers’ educational status, source of information and attitude towards the HPV vaccine were significantly associated with the knowledge of the HPV vaccine. Age, the source of information about the HPV vaccine and the grade level of students were significantly associated with multivariable logistic regression. Participants aged 13–15 were 2.1 times more likely to know about the HPV vaccine (AOR 1.70, 95% CI 1.17 to 3.88) as compared with those participants whose ages were 16–19 years old. Participants who have a source of information about the HPV vaccine are more likely to have good knowledge about the HPV vaccine than those who do not (AOR 1.94, 95% CI 1.06 to 3.22) (table 6).

    View this table:
    Table 6

    Factors associated with knowledge of human papillomavirus vaccine (HPV) among female adolescents in Debre Tabor Town, 2021

    Factors associated with acceptance of HPV vaccine

    The second model was fitted to assess factors associated with the acceptance of the HPV vaccine among female adolescent students. In multivariable logistic regression, variables such as school grade level, place of birth, father’s educational status, students who have the source of information about the HPV vaccine and cervical cancer, students who have taken the HPV vaccine and knowledge about the HPV vaccine were significantly associated with the acceptance of female adolescent students towards the HPV vaccine.

    Students’ urban places of birth were 1.55 times (AOR 1.55, 95% CI 1.15 to 1.95) more likely to have accepted the HPV vaccine as compared with those participants whose place of birth was in the rural area. Participants’ father’s educational status was secondary, and those above were 2.8 times (AOR 2.80, 95% CI 1.18 to 5.65) more likely to have positive acceptance of the HPV vaccine as compared with participants’ father’s educational status was non-formal education. Participants who had a source of information about the HPV vaccine were 2.14 times (AOR 2.14, 95% CI 1.05 to 4.32) more likely to have positive acceptance of the HPV vaccine as compared with those participants who had no information. Students who had good knowledge about the HPV vaccine were six times (AOR 6.41, 95% CI 3.45 to 11.90) more likely to have positive acceptance as compared with students who had poor knowledge (table 7).

    View this table:
    Table 7

    Factors associated with acceptance of human papillomavirus (HPV) vaccine and cervical cancer among female adolescents Years in Debre Tabor Town, 2021

    Discussion

    Having HPV vaccine knowledge and accepting the vaccine are known to be keystones for increasing the utilisation of the HPV vaccine. This study was assessing the knowledge and acceptability of the HPV vaccine and associated factors among female adolescent students in Debre Tabor Town.

    Less than half of HPV vaccine-eligible female students (41.7%) were fully immunised (two doses). This result was higher than a study conducted in China (11.0%).29 This vaccine utilisation is low and might be influenced by individuals’ knowledge and willingness to receive the HPV vaccine. However, 34.2% of students were not vaccinated for different reasons. The reasons were: students did not justify any reason (40%), some students planned to take the HPV vaccine next time (17.10%), 9.2% of participants were absent during the vaccination campaign, 8.6% had no information when the vaccine was given, 7.5% mentioned that the vaccine may be the cause of other diseases, 5.0% of participants mentioned fear of needle injection and 2.9% of students said the HPV vaccine causes infertility (2.9%). This study was supported by a systematic review and meta-analysis conducted in South Asia.29

    The proportion of knowledge about the HPV vaccine among female adolescent students was 59.2%. This was in line with the study conducted in Thailand (60%.0%) and the UK (54.8%).30 31 This result was higher than the study conducted in Malaysia,32 Iran (24%)33 and in Africa (37%)3; but lower than the study conducted in Romania (85.8%)34 and Italy(69.9%).35 The variation might be due to differences in the study setting, study population, and period of the study, the availability and distribution of the HPV vaccine among countries.

    Sixty-eight per cent (68.9%) of participants had the source of information about the HPV vaccine. This was higher than another nationwide survey.36 Students got the information about the HPV vaccine mainly through radio and television, and from health extension workers.

    In this study, the odds of having good knowledge about the HPV vaccine were inversely associated with participants’ age, 16–19 years old as compared with participants whose age was 13–15 years old. This finding was contrary to studies conducted in China, Nigeria and Morocco, respectively.14 18 21 This is explained by the fact that students might currently have more access to health information from health extension workers than students might have had earlier. Students who had sources of information about the HPV vaccine were more likely to have good knowledge about the HPV vaccine. When students receive information about the vaccine, they may easily understand when and how to give it.

    Almost two-thirds (61.9%) of those polled were willing to receive the HPV vaccine. This study was higher than the studies conducted in Nigeria (40%),18 Jimma, Ethiopia (36.8%),19 USA (52%),20 China (54%),37 and Morocco (27%).21 But higher than the study conducted in China (44%).38 This might be due to access to information about the HPV vaccine and the period of the study. Place of birth was significantly associated with HPV vaccine acceptability. Students who were born in urban areas were more likely to have good acceptance of the HPV vaccine as compared with their rural places of birth. This might imply that students born in towns have relatively easy access to information via social and mass media. Participants’ fathers who had secondary and above-average education were more likely to have good acceptance as compared with participants who had no formal education. This could be because parents with a secondary or higher level of education are more likely to be exposed to HPV vaccine information through school, mass media, newspapers and social media.

    Students who had the source of information about the HPV vaccine and cervical cancer prevention were more likely to experience the acceptability of the HPV vaccine than students who did not have information. This might help students understand the benefits of vaccination. Students who had good knowledge were more likely to have accepted the HPV vaccine as compared with those who had poor knowledge. This was similar to the study conducted in Italy.35 Students who provided evidence of the HPV vaccine’s benefits may be accepted and given the vaccine.

    Strengths and limitations of this study

    The results were more representative because the data came from a primary source. This study relied mainly on a quantitative approach, which could not address the ‘why’ questions in detail. Another limitation was that this study only included female students.

    Conclusion

    In this study, students’ knowledge and acceptance of the HPV vaccine were low. Participants, age and having a source of information were significantly associated with the knowledge of the HPV vaccine. The place of birth, the father’s educational status, the source of information about the HPV vaccine and cervical cancer prevention, and knowledge about the HPV vaccine were significantly associated with the acceptance of the HPV vaccine. Then, health authorities, through the mass media, should strengthen HPV vaccine promotion. Health extension workers and health professionals provide pertinent information on safety and vaccine effectiveness to parents in schools, churches, mosques and health facilities. Mixed quantitative and qualitative studies are better for further investigations to answer ‘why’ questions.

    Data availability statement

    All data relevant to the study are included in the article or uploaded as online supplemental information.

    Ethics statements

    Patient consent for publication

    Ethics approval

    This study involves human participants and was approved by Debre Tabor University College of medicine and Health Sciences. The reference number is DTU/RE/1/2095/2020. Participants gave informed consent to participate in the study before taking part.

    Acknowledgments

    We are high thanks to the Debre Tabor University College of Health Sciences for giving a written permission letter for conducting this study. We would like to express our gratitude to the Debre Tabor Twon education office for providing the necessary preliminary information and a supportive letter to conduct the study. We'd also like to thank the study's participants, supervisors and data collectors for their active participation.

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    Footnotes

    • Contributors GNM: involved in Conceived the idea, research proposal writing, data collection supervision, data entry and analysis, interpretation and manuscript writing. TML, ADA, HGB, TSY, ADM, BGK, AGT, ED, YYB, GAT, WNA, SGW, TMA involved in Data collection supervision, data analysis, and interpretation. All authors read and approved the final manuscript.

    • 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.