Factors Associated with Uptake of Human Papilloma virus Vaccine among Adolescent girls : A cross sectional survey on insights into HPV Infection Prevention in Kabarole District

Factors Associated with Uptake of Human Papilloma virus Vaccine among Adolescent girls : A cross sectional survey on insights into HPV Infection Prevention in Kabarole District | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Factors Associated with Uptake of Human Papilloma virus Vaccine among Adolescent girls : A cross sectional survey on insights into HPV Infection Prevention in Kabarole District Solomon Asiimwe, Fred N. Bagenda, Tony Mugisa This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4353752/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Human papilloma virus (HPV) infection imposes a substantial global disease burden and represents a critical public health concern. The persistently low uptake of HPV vaccination poses a significant obstacle to reducing cervical cancer incidence, particularly in remote rural areas of developing nations. Objective: This study aims to assess the extent of Human papilloma virus vaccine coverage among adolescents and explore the associated determinants to facilitate enhanced planning strategies within the Kabarole district. Methodology: Employing a cross-sectional survey approach, data were gathered from 240 adolescent girls residing in the Kabarole district between October 2021 and February 2022. Simple and multiple logistic regression analyses were employed to investigate the relationships between HPV vaccination uptake and various independent variables, including demographics, HPV knowledge, and health system factors. Results : Of the 240 adolescents enrolled, the overall prevalence of uptake of HPV vaccination was 63%. The uptake of human papilloma was associated with demographics knowledge about HPV and health systems factors. The multivariate analysis showed that parents who completed secondary level of education were 4.1 times more likely to take their children for HPV vaccination compared to parents whose education level was primary or had no formal education(AOR=4.06; 95%CI(0.69-0.087); p=0.004). Distance from home to facility was associated with uptake HPV vaccination. Participants who came from the distance of more than 5 km were 60% less likely to uptake HPV vaccination compared to those who come from 5km or less (OR=0.4; 95%CI (1.43 – 8.09); p=0.006). Results further revealed that parents whose knowledge about HPV vaccination was moderate were three times more likely to take up HPV vaccine compared to those whose knowledge was low (OR = 2.99; 95%CI(1.14 – 7.87); p=0.026). Conclusion : HPV vaccination uptake was at 63% and relatively lower than national average. Education of parents, Knowledge of HPV vaccination and distance to facility were factors significantly associated with uptake of Human papilloma virus vaccine Papilloma virus HPV Adolescent Human papilloma virus (HPV) Vaccination uptake Adolescent girls Kabarole district Demographics Knowledge Health system factors Logistic regression Prevalence Education level Distance to facility Cervical cancer Disease burden Public health Rural areas Figures Figure 1 Highlights Global Disease Burden: HPV infection is a significant global health concern, imposing a substantial disease burden. Low HPV Vaccination Uptake: There is persistently low uptake of HPV vaccination, particularly in remote rural areas of developing countries, posing a challenge to reducing cervical cancer incidence. Study Objective: The study aims to assess HPV vaccine coverage among adolescents and explore determinants to improve planning in the Kabarole district. Methodology: A cross-sectional survey was conducted among 240 adolescent girls in Kabarole district between October 2021 and February 2022. Simple and multiple logistic regression analyses were used to examine associations between HPV vaccination uptake and various factors. Prevalence of HPV Vaccination Uptake: Overall, 63% of adolescents enrolled in the study had received the HPV vaccine. The factors Influencing Vaccination Uptake: HPV vaccination uptake were associated with demographics variables of the participants, respondent’s knowledge about HPV, and health system factors. Parents with secondary education were more likely to vaccinate their children. Distance from home to facility also influenced uptake, with longer distances decreasing likelihood. Moderate parental knowledge about HPV vaccination significantly increased uptake. Introduction Human papilloma virus (HPV) infection has created a significant disease burden worldwide and is an important topic in public health (Kahn et al., 2007 ). HPV infection was the most common sexually transmitted infection (WHO, 2014 ). It was estimated that 75% of sexually active people were infected with HPV during their lifetime (Weaver et al., 2022 ). There are many genotypes of the HPV (Giuliano et al., 2011 ). HPV types 6 and 11 are the cause of 90% of cases of genital warts, whereas HPV types 16 and 18 were considered to be high-risk viruses, contributing to 70% of cases of cervical cancer(Workowski, Bolan, Centers for Disease, & Prevention, 2015 ; (McGuire, 2016 )). These virus sub-types underwent cytopathology changes, causing cervical intraepithelial neoplasia, which would eventually evolve to cervical cancer after approximately 2 decades (Workowski et al., 2015 ). Cervical cancer is the fourth leading cause of female cancer and ranks as the second most common form of cancer globally among females aged 15 to 44 years(Workowski et al., 2015 ). This is in comparison with other forms of common cancers including hepatobiliary, gall bladder and bile cancers (Benson et al., 2017 ) A 33.6% prevalence of human papilloma virus (HPV) among women in Uganda combined with low screening uptake (Chevarie-Davis et al., 2013 ) had resulted in the country having one of the highest cervical cancer incidence rates in the world (Nakisige, Schwartz, & Ndira, 2017 ). This is attributed to a number of factors including early marriages, multiple sexual partners, multi-parity, sexually transmitted infections including HIV infection (Katz et al., 2013 ), tobacco use, vitamin deficiency and HPV infection (WHO, 2019 ). Over 80% of diagnosed cases present with an advanced stage of the disease (Catharina J Alberts et al., 2017 ). Cervical cancer accounted for 5.2% of the cancer burden worldwide, leading to 530 000 new cases and 270 000 deaths every year for the past decade (Chevarie-Davis et al., 2013 ). Apart from cervical cancer, HPV can cause precancerous lesions, ano-genital warts and other cancers of the vulva, vagina, penis, anus, and oro-pharynx (Parkin & Bray, 2006 ). In Uganda, cervical cancer contributes 50–60% of all the female cancers and it is associated with a relative survival of approximately 20% (Banura et al., 2010 ). A prophylactic HPV vaccine was approved and licensed in 2006 (Lechuga et al., 2011 ), and was available since then, to prevent HPV associated infections targeting females aged 9 to 26 years (Markowitz et al., 2012 ). In late 2009, it was recommended that the quadrivalent HPV vaccine for males also be approved (Giuliano et al., 2011 ). By 2014, the Food and Drug Administration (FDA) approved another new HPV vaccine to provide additional protection against more types of HPV (Petrosky et al., 2015 ). Studies indicate that with an optimal coverage of about 70%, the life time risk of cervical cancer would be reduced by more than 50% (Banura et al., 2011 ). Many countries now include the HPV vaccination in their national vaccination program(Poljak, 2020 ). As many as 19 countries in Europe (Austria, Belgium, Denmark, France, Germany, Greece, Iceland, Ireland, Italy, Latvia, Luxembourg, the Netherlands, Norway, Portugal, Romania, Slovenia, Spain, Sweden, and the United Kingdom) introduced a program of routine HPV vaccinations in 2012. Coverage rates ranged from 17–84%, and 10 out of the 19 countries organized catch-up programs by May 2012 (Alberts et al., 2017 ). In Africa, a total of 21 developing countries including Uganda have implemented HPV vaccination projects among young girls under the support of a public-private partnership, the Global Alliance for Vaccines and Immunizations since 2013, and an estimated 206 000 girls from low-income countries were expected to benefit from these projects(Kamya et al., 2017 ). Specifically in Uganda, the vaccine was introduced in November 2015 and rolled out to all the districts including Kabarole, and it was given to girls aged 10 years, two doses with a time interval of six months after the first dose (Bowden, Yaun, & Bagga, 2017 ; Reiter et al., 2011 ; )). For this study, uptake referred to completion of the two recommended doses on schedule. Definition of subject matter The subject matter of the article titled "Factors Associated with Uptake of Human Papilloma virus Vaccine among Adolescent girls in Kabarole District: Insights into HPV Infection Prevention" centers around the factors influencing the acceptance and administration of the Human Papillomavirus (HPV) vaccine among adolescent girls in the Kabarole District. The title indicates a focus on understanding the determinants affecting the adoption of the HPV vaccine among adolescent girls specifically in the Kabarole District. The objective of the study is to explore and analyze the factors associated with the uptake of the HPV vaccine among adolescent girls in Kabarole District. This involves identifying various elements that influence the decision-making process regarding HPV vaccination. The study findings provide insights into the prevention of HPV infection through vaccination. By examining the factors influencing vaccine uptake, the study contributes to understanding how to improve vaccination rates and ultimately reduce the prevalence of HPV infection and related diseases such as cervical cancer. The study aims to shed light on the determinants of HPV vaccine uptake among adolescent girls in a specific geographic area, offering valuable insights for public health policymakers, healthcare providers, and community stakeholders involved in HPV infection prevention efforts Significance of the study The study findings were important for Kabarole district by providing insights on the factors that has led to the district failure to attain national targets for HPV vaccination. The district attainment of the national HPV vaccination targets is believed to reduce incidence of cervical cancer and other Human papilloma virus diseases among women. This will assist the district to join the rest of the world to strive for the achievement of the Sustainable Development Goal 3by reducing maternal mortality and preventable death among women. The study findings also provided insights on prevalence and factors leading to the low uptake of the second HPV vaccination in the district. This information is necessary to inform policy makers, health workers and community leaders to understand the causative factors for the low uptake of the HPV vaccine so that they can develop measures to increase the uptake of this very important vaccine. By identifying the associated factors to the low uptake of HPV vaccine, recommendations have been developed to support the district and health facilities within the district to implement blended strategies that can lead to improvement in the uptake of the HPV vaccine. Other researchers will use information as baseline to develop proposals for studies in this area and find out more about the HPV vaccination. the study findings can also improve ministry of health planning to address the HPV vaccine uptake problem and hence reduce the prevalence of cervical cancer in the county. Study objectives The study aim was to determine the uptake of human papilloma virus vaccine and associated factors among adolescent girls in Kabarole district. The study achieved its aim using the following objectives: To determine the uptake of Human papilloma virus vaccine coverage among adolescent girls aged 11 to 15 years in Kabarole district. To establish the socio-demographic and socio-economic factors associated with the uptake of Human papilloma virus vaccine among adolescent girls aged 11 to 15 years in Kabarole district. To establish the health system factors associated with the uptake of Human Papilloma virus vaccine among adolescent girls aged 11 to 15years in Kabarole district. by achieving the above objectives the study aimed to answer the following questions: What was the level of uptake of Human papilloma virus vaccine among adolescent girls aged 11to 15 years in Kabarole District? What are socio-demographic and socio economic factors associated with the uptake of the Human papilloma virus vaccine among adolescent girls aged 11 to 15 years in Kabarole District? What are the health system factors associated with the uptake of Human Papilloma virus vaccine among adolescent girls aged 11 to 15years in Kabarole district. Materials and Methods Study Design, Setting and Procedures Between December 2017 and July 2018, we conducted a A cross-sectional study design employing both quantitative and qualitative research methods was used. The study was done in Kabarole District, which was one of the districts in Uganda where this programme was first rolled out in the country in 2015. The district is located in Western regiion of Uganda, about 300 km from the city center of Kampala. The district is bordered by Bunyangabu district in the West, Kamwenge in the South, Kyenjojo in the East, Bundibugyo and Ntoroko in the North and by Kibaale in the Northeast. The district had 38 health facilities. In terms of level of facility, the district has 4 hospitals, 2 health sub districts, 18 health center IIIs and 14 Health center IIs and all facilities conduct HPV vaccination at both static and outreach sites. The district is made up of two counties that is Burahya county and Fort portal Tourism city. The district is further subdivided into 11sub counties, 4 town councils and 3 divisions (total of 18). According to UBOS report on population survey (2017), Kabarole district has an estimated total population of 302,923 people. The target population was adolescent female girls aged between 11 to 15 years, because they are in the age bracket of those who should have completed the Human papilloma virus vaccination schedule by the time of the study since the national rollout of the vaccination programme in 2015. For each adolescent girl, the caretaker was interviewed to get the caretaker related factors. The immunization focal person or in charge of the corresponding health facility in the selected sub county was engaged in a key informant interview. The study involved multistage sampling. This method was considered appropriate because the population was large and widely scattered in the district. The primary sampling unit (PSU) was the district considered as the first sampling stage. The secondary sampling unit (SSU) were the sub-counties as the second sampling stage, parishes as the third sampling stage, households as the fourth sampling stage and then further sampling of individuals within each household selected as the fifth secondary sampling unit. From each sub county, one parish was selected by simple random sampling, where all the parishes were given numbers. The villages in each parish were be selected randomly using simple random sampling from the list of villages registered at the sub county. A total of eight (8) villages were selected. A proportion to size was used to select households and then systemic random sampling method were used. A list of households in the selected villages having adolescent girls aged between 11 and 15 years was generated using information from the village health teams. The design effect of 1.106 was factored in computation of the sample size. The sample size adjusted for design effect was 240 young girls. For key informant interviews, 6 EPI focal persons or the in charge of a health facility which was in the selected sub county was also interviewed using a prepared checklist. Measurement of Knowledge about HPV vaccination. Knowledge about HPV vaccination by both the adolescent girl and the caretaker was measured using the ten standard questions in section 2 of the respective tools. Those who answered correctly any nine of the questions were considered to have high knowledge, those who answered any five questions were considered to have moderate knowledge and those who answered any four or less questions were considered to have low knowledge. These questions in the tools were tested and had a content validity index of 0.76 from two experts. Data Collection Quantitative data was collected by interviews using an interviewer administered semi structured questionnaire. The data included the social demographic factors, knowledge about HPV vaccination and uptake. The adolescent girls were asked whether they have received the HPV vaccine and the number of doses with evidence and those without evidence were considered not vaccinated. The caretaker of the adolescent girl was interviewed using a separate interview guide. A content validity index of 0.76 was obtained from two experts. The questionnaires were pretested on 10 adolescent girls in a nearby village before the final use for the study. A Cronbach's alpha of 0.79 was obtained. Qualitative data were collected from key informants using a key informant’s guide and the audios recorded. Data was collected between October 2021 and February 2022 ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"T0PN5Odc","properties":{"formattedCitation":"(Nabirye et al., 2020 )","plainCitation":"(Nabirye et al., 2020 )","noteIndex":0},"citationItems":[{"id":516,"uris":[" http://zotero.org/users/13672379/items/6IP77YV7"],"itemData":{"id":516,"type":"article-journal","abstract":"In the original article [1] the first paragraph of the Background section was omitted due to a discrepancy between the metadata of the article and the PDF version.","container-title":"BMC Public Health","DOI":" 10.1186/s12889-020-8348-y","ISSN":"1471–2458","issue":"1","journalAbbreviation":"BMC Public Health","language":"en","page":"491","source":"DOI.org(Crossref)","title":"Correction to: Health system factors influencing uptake of human papilloma virus (HPV) vaccine among adolescent girls 9–15 years in Mbale District, Uganda","title-short":"Correction to","volume":"20","author":[{"family":"Nabirye","given":"Juliet"},{"family":"Okwi","given":"Livex Andrew"},{"family":"Nuwematsiko","given":"Rebecca"},{"family":"Kiwanuka","given":"George"},{"family":"Muneza","given":"Fiston"},{"family":"Kamya","given":"Carol"},{"family":"Babirye","given":"Juliet N."}],"issued":{"date-parts":[["2020",12]]}}}],"schema":" https://github.com/citation-style-language/schema/raw/master/csl-citation.json" } (Nabirye et al., 2020 )(Muellmann et al., 2021 ). Measurement of key study variables Dependent variables The dependent variable for this study were uptake of Human papilloma virus vaccine (HPV) which was classified into fully vaccinated and not fully vaccinated, where fully vaccination means having taken all the two doses on time or schedules as evidenced by the child vaccination card or a recall of receiving two doses of the vaccine on the left upper arm. Independent variables These included individual factors such as knowledge and perception of the adolescent girls and parents/caretakers, socio-demographics, cultural factors, and health facility factors, such as availability of the HPV vaccination services in the health facilities, mode of service delivery like health facility based or outreach based, consistency of the vaccination services at the health facilities, availability of the required equipment’s for HPV vaccination at the health facilities. Data Management and Statistical Analysis Data collected from the questionnaires were inspected for errors and gaps. After inspection and editing, it was entered into excel version 12. Questions were coded and analyzed using STATA version 15. Data were entered and verified in Ms-Excel and exported to. Stata 15 software. Stata Corporation, College Station, USA was used for analyses. The data was analyzed at three different levels; univariate, bivariate and multivariate using the binary logistic regression model. Bivariate associations were done to test any possible associations between each of the independent variables and the dependent variable. Statistical significance of the relationships was determined for the P-value (P < 0.2) and all significant variables at this level were considered at multivariate level of analysis. Multivariate analysis was performed to assess which factor was associated with the uptake of HPV vaccination more than the other. The HPV was classified into fully vaccinated and not fully vaccinated. Thus HPV vaccination is a nominal (Binary/dichotomous) variable and therefore the suitable model to analyze this kind of criterion variable is the binary logistic regression. Binary logistic regression analysis was used because it attempts to control for possible confounding effect of independent variables on each other and thus finds the independent association for each predictor variable with the criterion variable (Kirkwood, 1981 ). For qualitative data, audio tape recordings were transcribed verbatim, coded and uploaded in the qualitative data analysis software MAXQDA version 12 for analysis. Cut and paste approach was used for best quotes to triangulate quantitative information as best quotes. Ethics The study was approved by the research and ethics committee of Mbarara University of science and technology and by the Uganda National Council for Science and Technology. Results of the 240 caretakers of female adolescents aged 11 to 15 years in Kabarole district enrolled into the study, the majority were Batoro, 153(65.7%), married/cohabiting, 140 (52.6%), residing in a rural setting, 152 (66.3%) and 229 (95.4%) earned a net income less than 100,000 Uganda shillings. The mean age for parents/caregivers was 38.53 (SD = 8.75) years (Table 1 ). HPV vaccination coverage was at 62.5% (n = 150),95% CI (0.562–0.684) (Fig. 1 ). Multivariate analysis was performed to assess which factors were associated with uptake of human papilloma virus vaccine. Binary logistic regression model was used since the outcome variable was binary/dichotomous. At a multivariate level, all factors which had p-values below the threshold of 0.2 at the bivariate analysis were included in the multivariate model (Table 2 ). A reference category was selected for each categorical variable. The multivariate analysis showed that parents who completed secondary level of education were 4.1 times more likely to take their children for HPV vaccination compared to parents whose education level was primary or had no formal education Adjusted Odds Ratio (AOR) (AOR = 4.06; 95%CI (1.69–6.87 ); p = 0.004). Furthermore, distance from home to facility where the services of HPV vaccination were, was also associated with uptake HPV vaccination. Participants who came from the distance of more than 5 km were 60% less likely to uptake HPV vaccination compared to those who come from 5km or less (AOR = 0.4; 95%CI (0.34–0.89); p = 0.006). The multivariate analysis further revealed that parents whose knowledge about HPV vaccination was moderate were three times more likely to take up HPV vaccine compared to those whose knowledge was low (AOR = 2.99; 95%CI (1.14–7.87); p = 0.026). Other factors like tribe of caregiver, age of parent, impact of Religion on child HPV vaccination, and impact of clan on child HPV were not significantly associated with uptake of human papilloma virus vaccine at multivariate analysis. Table 1 Socio-demographic characteristics of the respondents (N = 240) n(%) Age (years) Adolescent Mean = 12.71, SD = 1.33) < 13 107(44.6) 13–15 133(55.4) Age (years) caretaker Mean = 38.53, SD = 8.75) 25–34 years 79 (32.9) 35–44 years 117 (48.8) ≥ 44 years 44 (18.3) Education ≤Primary 215(90.3) Secondary 23(23.7) Gender of the caretaker Male 109(45.4) Female 131(54.6) Education Adolescent ≤Primary 136(57.1) Secondary 102(42.9) Tribe of Adolescent Mutoro 153 (65.7) Others 87 (36.3) Religious affiliation of caretaker Anglican 82 (34.3) Catholic 114 (47.7) Others 44 (18.3) Marital status of caretaker Single 68 (28.3) Married/cohabiting 130 (54.2) Cohabiting 18 ( 7.5) Widowed/ 6 ( 2.5) Divorced/separated 18 ( 7.5) Residence Rural 152 (66.3) Urban 88 (36.7) Occupation of caretaker Unemployed 110 (46.0) Peasant/Farmer 108 (45.2) Business 22 ( 9.2) Average monthly income (Ugandan shillings) of caretaker < 100,000 229 (95.4) ≥ 100,000 11 ( 4.6) Table 2 Multivariate analysis results of factors associated with the uptake of Human papilloma virus vaccine among adolescent girls aged 11 to 15 years in Kabarole district (n = 240) Variables AOR 95%CI P_value Education of caretaker Primary/no formal education 1 Post-Secondary 4.06(1.69–6.87) 0.004** Tribe of caretaker Mutoro 1 Others 1.13 (0.47–2.67) 0.789 Distance from home to facility ≤ 5km 1 > 5km 0.4 (0.34–0.89) 0.006** Age of caretaker 44 years 0.70(0.23–2.11) 0.529 HPV knowledge of caretaker Low 1 Moderate 2.99 (1.14–7.87) 0.026** High 2.21 (0.86–5.69 0.102 Impact of Religion on child HPV vaccination Yes 1 No 0.61(0.18–2.02) 0.418 Impact of clan on child HPV vaccination Yes 1 No 0.57(0.17–1.95) 0.374 **Statistical significant (p ≤ 0.05) at multivariate analysis Discussion This household-based cross-sectional study among adolescent females aged 11 to 15 years in Kabarole district, HPV vaccination coverage was at 63%. Uganda Ministry of Health reported an annualized HPV coverage of 85% for HPV 1 and as low as 41% (Patrick et al., 2022 )for HPV 2 as of December 2017(WHO 2019 ). In Kabarole district, they reported high HPV1 vaccine coverage at 114%, but still very low HPV2 vaccine coverage at 51% in 2017 (Ministry of Health 2017), HPV1 at 110% and HPV2 at 50% in 2018 (Ministry of Health 2018) and HPV 1 at 91% and HPV2 at 64% in 2019 (Ministry of Health 2019) this is in line with the findings from the study by Chuang et al who concluded that efforts to improve HPV initiation and completion could benefit from additional attention to factors at the health care (Chuang et al., 2017 ). According to a study carried out in Soweto South Africa, of 224 adolescents recruited, 201 initiated the vaccine; 192 (95.5%) received a second immunization; and 164 (81.6%) completed three doses. In that qualitative study, of 39 adolescent-caregivers, it was found out that factors driving vaccine uptake reflected a socio-cultural backdrop of high HIV endemnicity, sexual violence, poverty, and an abundance of female-headed households (Katz et al. 2013 ; Bair et al., 2008 ). Findings from a study by Migoneetal, HPV vaccine uptake in Ireland was high. Even in schools that are disadvantaged, HPV was above the national target of 80%. Since then, anti-HPV vaccine publicity has had a negative impact on national HPV vaccine uptake in Irish schools. The study also found out that even notwithstanding recent anti- HPV vaccine publicity, school-based programmes, such as the Irish HPV vaccination programme have been shown to maximize uptake of vaccines when compared with opportunistic community based programmes (Kessels et al., 2012 ). The study by Migoneetal, demonstrates that inequity in uptake may persist in school based programmes while the difference in mean and median uptake between disadvantaged schools and other Irish schools in Irish study was small, the majority of schools with the lowest uptake (≤ 50%) were disadvantaged. Disadvantaged schools were twice as likely to have an uptake of ≤ 50% when compared with other schools, independent of other school characteristics (Kessels et al., 2012 ). Lower HPV vaccine uptake in disadvantaged schools has been reported by other studies; In Manchester, uptake was significantly lower in more deprived areas while in Ontario, Canada, uptake of HPV vaccine in schools was lower in girls from lower income backgrounds (Fisher et al., 2014 ). Findings from a longitudinal study carried out in Eldoret, Kenya, where HPV vaccine acceptability was measured before a vaccination program (n = 287) and vaccine uptake, as reported by mothers, once the program was finished (n = 256) indicates that even though baseline acceptance was very high (88.1%), only 31.1% of the women reported at follow-up that their daughters had been vaccinated. The vaccine was declined by 17.7%, while another 51.2% had wanted the vaccination but were obstructed by practical barriers including cultural acceptance related barriers (Joseph et al., 2012 ; Vermandere et al., 2014 ). A study conducted in Lira district, Uganda, on the level and factors associated with the uptake of HPV vaccine among adolescent girls aged between 12 and 17 years also demonstrated low uptake where 49.6%(228/460) had not taken any of the vaccines, 18%(83/460) had received one dose, 14.8%(68/460) had received two doses and the uptake was associated with factors like education and other social economic factors (Kisaakye et al., 2018 ; Isabirye et al., 2020 ) . Knowledge of HPV vaccination and distance to facility were the factors associated with uptake of Human papilloma virus vaccine among adolescent girls aged 11 to 15 years in Kabarole district. Baseline information on knowledge, attitude and practice towards HPV vaccination was crucial in establishing a progress track on the current HPV immunization program (Jalani et al., 2019 ). In a study conducted in Malaysia with a total sample of 380 respondents who participated in this study. Females scored significantly higher for the knowledge i tems compared to the males. Majority of respondents (86.6%) indicated their intention to get HPV vaccines. Willingness to be vaccinated was significantly associated with the level of knowledge of cervical cancer (AOR 1.66; 95% CI 1.018–2.698; p = 0.042). Gender (AOR 3.29; 95% CI 2.00-5.41; p < 0.001) lack of knowledge was found to be a significant predictor for someone who rejects vaccination due to side effects (Jalani et al., 2019 ). The study conducted by Satterwhite CL in Malaysia concluded that knowledge of HPV and its preventive measures among the respondents were still insufficient. Attitude towards HPV vaccination was significantly associated with knowledge about cervical cancer (Lechuga et al., 2011 ). In addition, vaccination practice among secondary school girls was high, indicating that the national HPV immunization program was effective in delivering the HPV vaccine (Satterwhite et al., 2013 ). Since acceptance of HPV vaccination varies internationally, and many adolescents were still not getting the HPV vaccine in various countries (Wigle et al., 2013 ), it was important to understand why some parents choose to vaccinate their children and some parents do not in order to continue to increase vaccination uptake. According to the study conducted by Brooke Nickel 2017, both low and high HPV knowledge may be associated with lower rates of vaccination, with parents' country and gender also being influential factors. It also demonstrated that parental attitudes towards the HPV vaccine differ by country and knowledge (Nickel et al., 2017 ). Given that the primary target population for HPV vaccination program was girls aged 9–13, typically before the initiation of sexual accident, parental knowledge and attitudes play an important role in the success of vaccination as consent was usually required for their adolescent children to be vaccinated. Research aimed at understanding HPV vaccine uptake has demonstrated that uptake of the HPV vaccine was generally high with good knowledge about the vaccine, however parents and girls often had insufficient knowledge and understanding about and had varying attitudes towards vaccination (Hendry et al., 2013 ). Alongside this, several studies conducted across different settings have aimed to examine factors influencing HPV vaccine uptake. Findings from these studies were wide-ranging, however, parental intentions have been shown to consistently be a strong predictor of their children's HPV vaccine uptake (C. J. Alberts et al., 2017 ). According to the findings by Brooke 2017, the strongest factor associated with daughters' vaccination status across the entire sample was parents' HPV knowledge ( p < 0.001). Parents' HPV knowledge scores displayed a non-linear relationship; parents with low knowledge scores and parents with high knowledge scores were less likely to have vaccinated their daughters. HPV vaccination specific knowledge was also significant univariate factor associated with vaccination status ( p < 0.05) (Hendry et al., 2013 ). Vaccination specific knowledge and very high levels of vaccination specific knowledge were also less likely to have vaccinated their daughters. Parents' demographic characteristics including their country of origin (OR = 2.2, 95% CI: 1.07–4.50; p < 0.05) and gender (OR = 0.5 95% CI: 0.26–0.94, p < 0.05) were also factors associated with non-vaccination, with parents in the US and men (across all countries) being less likely to vaccinate their daughters (Kessels et al., 2012 ). This is also in line with a study conducted in Ethiopia Debre Tabar Town by Gedefaye in which secondary education and above (AOR 1.70, 95% CI 1.05–2.27) and having good knowledge of the HPV vaccine (AOR 3.30, 95% CI 2.21–4.93) were significantly associated with willingness to receive the HPV vaccine. From the qualitative analysis, it was reported that some villages in Kabende are hard to reach and it is worse in the rainy season when the road network is poor. This is consistent with the findings on the quantitative analysis where long distance to the health facilities (Nabirye et al., 2020 ) was associated with poor uptake of the vaccination. The long distance with a poor road network makes it hard for the adolescents to access the vaccination points (Kessels et al., 2012 ). In Summary, the findings in this study are consistent with the results in other studies where the uptake and completion of the vaccination programme is still a challenge (Joseph et al., 2012 ). Also the findings on the factors associated with the uptake from this study are consistent with the findings in other studies where knowledge about the vaccine by both the adolescent girl and caretaker, level of education by the caretaker and accessibility to the vaccination points are strongly associated with uptake of the vaccine (Kahn et al., 2007 ). From this study, it was also established that most HPV vaccination programmes target girls aged less than 12 years old or those in primary school, which enables them to get the best protection. Most girls at secondary school level have already started sexual debut, so it is very important for them to complete the HPV vaccination before they start secondary education(Whelan, 2016 ). Conclusion In conclusion, this study provides a preliminary insight into the uptake of human papillomavirus vaccine among adolescent girls in Kabarole district. HPV vaccination uptake was at 63% and relatively lower than national average. Education of caretaker, Knowledge of HPV vaccination and distance to facility were the factors associated with uptake of Human papilloma virus vaccine among adolescent girls aged 11 to 15 years in Kabarole district. Abbreviations Cacx: Cancer of the cervix CI: Confidence Interval ELISA: Enzyme Linked Immune Absorbent Assays FREC: Faculty Research and Ethics Committee HCIII: Health Center Three HIV: Human Immune Virus HMIS: Health Management Information Systems HPV: Human papilloma virus HPV 1: Human papilloma virus vaccine first dose HPV 2: Human papilloma virus vaccine second dose MoH: Ministry of Health MUST: Mbarara University of Science and Technology PCR: Polymerase Chain Reaction RDTs: Rapid Diagnostic Test REC: Research and Ethics Committee UDHS: Uganda Demographic Health Surveys UBOS: Uganda Bureau of Statistics UGX: Uganda Shillings VHT: Village Health Team WHO: World Health Organization Declarations Ethics approval and consent to participate Norm/Standard according to which research was conducted: This research was conducted adhering to guidelines set forth by the Declaration of Helsinki, which outlines ethical principles for medical research involving human subjects. The research was approved by the Research and Ethics committee of the Faculty of Medicine of Mbarara University of science and technology, and to the research and ethics committee of Mbarara University of science and technology. The study protocol was aligned with ethical guidelines. Informed consent was obtained from study participants and their guardians, Participants in the study were ensured of confidentiality of their data, minimization of potential harm and discomfort, and respect for participant autonomy and dignity was maintained. Additionally, the study adhered to relevant national and institutional regulations regarding research involving human subjects and disclosed any potential conflicts of interest. Authorization to carry out the study was obtained from the health sub district authorities, education officer, and the district health office authorities in the study area. More so authorization to interview health workers was obtained from their facility managers before they could participate in the study. The objectives of the study were explained to study participants and/or their guardians and written consent was obtained when consented to participlate in the study. The consent form was signed in duplicate, and one copy remained with the participant. To ensure privacy and confort to the participants, participant were interviewed from a selected private place at their home, workplace or school. All participants in the study were assured that they were free to pull out of the study in case they feel uncomfortable and that no consequences at all were to be gotten for the respondents who decide to move out of the study. The respondents were told that no names were required as the information given was solely for academic research purposes. Consent for publication All the authors of this manuscript were fully consulted and all do consent to publish this article Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interest The authors have declared that there are no competing interests. Funding: The research was not sponsored by any government or agency ORCID iDs: Tony Mugisa, Dip CM, BSc PH, MPH iD : https://orcid.org/0009-0008-9559-1179 Author contribution SA, and TM conceptualized the research work, TM and SA conducted Data collection, Data analysis and drafted the manuscript, SA, FNB, and TM did final revision; SA, FNB and TM Read and approved final manuscript. SA, FNB, and TM reviewed and approved the manuscript, and also conducted the literature search. All authors read and approved the final manuscript. Authors’ abbreviations SA: Solomon Asiimwe; TM: Tony Mugisa; FNB: Fred Norman Bagenda Acknowledgement the Authors thank the research assistants for their integrity and hard work in collecting the data, the teachers of the participating schools for their cooperation and the health workers who provided valuable information for this study. The authors also acknowledge all researchers whose findings helped in the development of this manuscript. The Authors also thank all the study participants- adolescent girls in Kabarole district, for accepting to participate in the study. Authors and Affiliations Department of Post Public Health, Faculty of Health Sciences, Mountains of the Moon University, Fort Portal City, Uganda Tony Mugisa Department of Community Health, Faculty of Health sciences, Mbarara University of Science and Technology, Mbarara City, Uganda Solomon Asiimwe and Authors and Affiliations Corresponding author Tony Mugisa References Banura, C., Mirembe, F. M., Katahoire, A. R., Namujju, P. B., Mbonye, A. K., & Wabwire, F. M. (2011). Epidemiology of HPV genotypes in Uganda and the role of the current preventive vaccines: A systematic review. Infect Agent Cancer, 6 (1), 11. doi: 10.1186/1750-9378-6-11 Banura, C., Sandin, S., van Doorn, L. J., Quint, W., Kleter, B., Wabwire-Mangen, F., . . . Weiderpass, E. (2010). Type-specific incidence, clearance and predictors of cervical human papillomavirus infections (HPV) among young women: a prospective study in Uganda. Infect Agent Cancer, 5 , 7. doi: 10.1186/1750-9378-5-7 Bowden, M., Yaun, J., & Bagga, B. (2017). Improving Human Papilloma Virus Vaccination Rates: Quality Improvement. Pediatr Qual Saf, 2 (6), e048. doi: 10.1097/pq9.0000000000000048 Fisher, H., Audrey, S., Mytton, J. A., Hickman, M., & Trotter, C. (2014). Examining inequalities in the uptake of the school-based HPV vaccination programme in England: a retrospective cohort study. [Research Support, Non-U.S. Gov't]. 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Correction to: Health system factors influencing uptake of human papilloma virus (HPV) vaccine among adolescent girls 9-15 years in Mbale District, Uganda. [Published Erratum]. BMC Public Health, 20 (1), 491. doi: 10.1186/s12889-020-8348-y Nakisige, C., Schwartz, M., & Ndira, A. O. (2017). Cervical cancer screening and treatment in Uganda. [Review]. Gynecol Oncol Rep, 20 , 37-40. doi: 10.1016/j.gore.2017.01.009 Nickel, B., Dodd, R. H., Turner, R. M., Waller, J., Marlow, L., Zimet, G., . . . McCaffery, K. (2017). Factors associated with the human papillomavirus (HPV) vaccination across three countries following vaccination introduction. Prev Med Rep, 8 , 169-176. doi: 10.1016/j.pmedr.2017.10.005 Parkin, D. M., & Bray, F. (2006). Chapter 2: The burden of HPV-related cancers. [Review]. Vaccine, 24 Suppl 3 , S3/11-25. doi: 10.1016/j.vaccine.2006.05.111 Patrick, L., Bakeera-Kitaka, S., Rujumba, J., & Malande, O. O. (2022). Encouraging improvement in HPV vaccination coverage among adolescent girls in Kampala, Uganda. PLoS One, 17 (6), e0269655. doi: 10.1371/journal.pone.0269655 Petrosky, E., Bocchini, J. A., Jr., Hariri, S., Chesson, H., Curtis, C. R., Saraiya, M., . . . Prevention. (2015). Use of 9-valent human papillomavirus (HPV) vaccine: updated HPV vaccination recommendations of the advisory committee on immunization practices. MMWR Morb Mortal Wkly Rep, 64 (11), 300-304. Poljak, M. (2020). Simplification of hepatitis C testing: a time to act. [Review]. Acta Dermatovenerol Alp Pannonica Adriat, 29 (3), 129-132. Satterwhite, C. L., Torrone, E., Meites, E., Dunne, E. F., Mahajan, R., Ocfemia, M. C., . . . Weinstock, H. (2013). Sexually transmitted infections among US women and men: prevalence and incidence estimates, 2008. [Review]. Sex Transm Dis, 40 (3), 187-193. doi: 10.1097/OLQ.0b013e318286bb53 Vermandere, H., Naanyu, V., Mabeya, H., Vanden Broeck, D., Michielsen, K., & Degomme, O. (2014). Determinants of acceptance and subsequent uptake of the HPV vaccine in a cohort in Eldoret, Kenya. [Research Support, Non-U.S. Gov't]. PLoS One, 9 (10), e109353. doi: 10.1371/journal.pone.0109353 Weaver, A., Smith, M., Wilson, S., Douglas, C. M., Montgomery, J., & Finlay, F. (2022). Palliation of head and neck cancer: a review of the unique difficulties. [Review]. Int J Palliat Nurs, 28 (7), 333-341. doi: 10.12968/ijpn.2022.28.7.333 Whelan, A. M. (2016). Lowering the Age of Consent: Pushing Back against the Anti-Vaccine Movement. J Law Med Ethics, 44 (3), 462-473. doi: 10.1177/1073110516667942 WHO. (2014). Comprehensive cervical cancer control: a guide to essential practice: World Health Organization Geneva. WHO. (2019). Uganda embarks on a multisectoral approach to improve Vaccination coverage against Human Papillomavirus: WHO Regional Office for Africa Uganda. Wigle, J., Coast, E., & Watson-Jones, D. (2013). Human papillomavirus (HPV) vaccine implementation in low and middle-income countries (LMICs): health system experiences and prospects. [Research Support, Non-U.S. Gov't Review]. Vaccine, 31 (37), 3811-3817. doi: 10.1016/j.vaccine.2013.06.016 Workowski, K. A., Bolan, G. A., Centers for Disease, C., & Prevention. (2015). Sexually transmitted diseases treatment guidelines, 2015. [Practice Guideline Alberts, C. J., Van Der Loeff, M. F. S., Hazeveld, Y., De Melker, H. E., Van Der Wal, M. F., Nielen, A., El Fakiri, F., Prins, M., & Paulussen, T. G. W. M. (2017). A longitudinal study on determinants of HPV vaccination uptake in parents/guardians from different ethnic backgrounds in Amsterdam, the Netherlands. BMC Public Health , 17 (1), 220. https://doi.org/10.1186/s12889-017-4091-4 Bair, R. M., Mays, R. M., Sturm, L. A., Perkins, S. M., Juliar, B. E., & Zimet, G. D. (2008). Acceptability to Latino Parents of Sexually Transmitted Infection Vaccination. Ambulatory Pediatrics , 8 (2), 98–103. https://doi.org/10.1016/j.ambp.2007.11.002 Benson, A. B., D’Angelica, M. I., Abbott, D. E., Abrams, T. A., Alberts, S. R., Anaya, D. A., Are, C., Brown, D. B., Chang, D. T., Covey, A. M., Hawkins, W., Iyer, R., Jacob, R., Karachristos, A., Kelley, R. K., Kim, R., Palta, M., Park, J. O., Sahai, V., … Darlow, S. (2017). NCCN Guidelines Insights: Hepatobiliary Cancers, Version 1.2017. Journal of the National Comprehensive Cancer Network , 15 (5), 563–573. https://doi.org/10.6004/jnccn.2017.0059 Chevarie-Davis, M., Ramanakumar, A. V., Ferenczy, A., Villa, L. L., & Franco, E. L. (2013). Assessment of the performance of algorithms for cervical cancer screening: Evidence from the Ludwig–McGill cohort study. Gynecologic Oncology , 128 (3), 415–419. https://doi.org/10.1016/j.ygyno.2012.12.008 Chuang, E., Cabrera, C., Mak, S., Glenn, B., Hochman, M., & Bastani, R. (2017). Primary care team- and clinic level factors affecting HPV vaccine uptake. Vaccine , 35 (35), 4540–4547. https://doi.org/10.1016/j.vaccine.2017.07.028 Giuliano, A. R., Palefsky, J. M., Goldstone, S., Moreira, E. D., Penny, M. E., Aranda, C., Vardas, E., Moi, H., Jessen, H., Hillman, R., Chang, Y.-H., Ferris, D., Rouleau, D., Bryan, J., Marshall, J. B., Vuocolo, S., Barr, E., Radley, D., Haupt, R. M., & Guris, D. (2011). Efficacy of Quadrivalent HPV Vaccine against HPV Infection and Disease in Males. New England Journal of Medicine , 364 (5), 401–411. https://doi.org/10.1056/NEJMoa0909537 Hendry, M., Lewis, R., Clements, A., Damery, S., & Wilkinson, C. (2013). “HPV? Never heard of it!”: A systematic review of girls’ and parents’ information needs, views and preferences about human papillomavirus vaccination. Vaccine , 31 (45), 5152–5167. https://doi.org/10.1016/j.vaccine.2013.08.091 Isabirye, A., Mbonye, M., Asiimwe, J. B., & Kwagala, B. (2020). Factors associated with HPV vaccination uptake in Uganda: A multi-level analysis. BMC Women’s Health , 20 (1), 145. https://doi.org/10.1186/s12905-020-01014-5 Joseph, N. P., Clark, J. A., Bauchner, H., Walsh, J. P., Mercilus, G., Figaro, J., Bibbo, C., & Perkins, R. B. (2012). Knowledge, Attitudes, and Beliefs Regarding HPV Vaccination: Ethnic and Cultural Differences Between African-American and Haitian Immigrant Women. Women’s Health Issues , 22 (6), e571–e579. https://doi.org/10.1016/j.whi.2012.09.003 Kahn, J. A., Lan, D., & Kahn, R. S. (2007). Sociodemographic Factors Associated With High-Risk Human Papillomavirus Infection. Obstetrics & Gynecology , 110 (1), 87–95. https://doi.org/10.1097/01.AOG.0000266984.23445.9c Katz, I. T., Nkala, B., Dietrich, J., Wallace, M., Bekker, L.-G., Pollenz, K., Bogart, L. M., Wright, A. A., Tsai, A. C., Bangsberg, D. R., & Gray, G. E. (2013). A Qualitative Analysis of Factors Influencing HPV Vaccine Uptake in Soweto, South Africa among Adolescents and Their Caregivers. PLoS ONE , 8 (8), e72094. https://doi.org/10.1371/journal.pone.0072094 Kessels, S. J. M., Marshall, H. S., Watson, M., Braunack-Mayer, A. J., Reuzel, R., & Tooher, R. L. (2012). Factors associated with HPV vaccine uptake in teenage girls: A systematic review. Vaccine , 30 (24), 3546–3556. https://doi.org/10.1016/j.vaccine.2012.03.063 Kirkwood, B. R. (1981). Chi-square test for contingency tables. British Journal of Hospital Medicine , 25 (3), 291–292. Lechuga, J., Swain, G. R., & Weinhardt, L. S. (2011). The Cross-Cultural Variation of Predictors of Human Papillomavirus Vaccination Intentions. Journal of Women’s Health , 20 (2), 225–230. https://doi.org/10.1089/jwh.2010.1993 McGuire, S. (2016). World Cancer Report 2014. Geneva, Switzerland: World Health Organization, International Agency for Research on Cancer, WHO Press, 2015. Advances in Nutrition , 7 (2), 418–419. https://doi.org/10.3945/an.116.012211 Muellmann, S., Brand, T., Jürgens, D., Gansefort, D., & Zeeb, H. (2021). How many key informants are enough? Analysing the validity of the community readiness assessment. BMC Research Notes , 14 (1), 85. https://doi.org/10.1186/s13104-021-05497-9 Nabirye, J., Okwi, L. A., Nuwematsiko, R., Kiwanuka, G., Muneza, F., Kamya, C., & Babirye, J. N. (2020). Correction to: Health system factors influencing uptake of human papilloma virus (HPV) vaccine among adolescent girls 9–15 years in Mbale District, Uganda. BMC Public Health , 20 (1), 491. https://doi.org/10.1186/s12889-020-8348-y Patrick, L., Bakeera-Kitaka, S., Rujumba, J., & Malande, O. O. (2022). Encouraging improvement in HPV vaccination coverage among adolescent girls in Kampala, Uganda. PLOS ONE , 17 (6), e0269655. https://doi.org/10.1371/journal.pone.0269655 Reiter, P. L., McRee, A.-L., Gottlieb, S. L., & Brewer, N. T. (2011). Correlates of receiving recommended adolescent vaccines among adolescent females in North Carolina. Human Vaccines , 7 (1), 67–73. https://doi.org/10.4161/hv.7.1.13500 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4353752","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":299169699,"identity":"4425a4f1-add7-4b18-80a6-2812b2dababd","order_by":0,"name":"Solomon Asiimwe","email":"","orcid":"","institution":"Mbarara University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Solomon","middleName":"","lastName":"Asiimwe","suffix":""},{"id":299169702,"identity":"17e66e72-d228-41e2-82fe-76357e188071","order_by":1,"name":"Fred N. Bagenda","email":"","orcid":"","institution":"Mbarara University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Fred","middleName":"N.","lastName":"Bagenda","suffix":""},{"id":299169704,"identity":"904527cd-01af-4f22-bf85-81d0158c977b","order_by":2,"name":"Tony Mugisa","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABFUlEQVRIiWNgGAWjYDADNgYGxgcJBjVyIM6BB3hU8iBpYTb4UHDMGKwlgRgtIF2SMz4wJzaAmPi02LP3HpP4mXPYro//8ANpHgO29Plhhx8CbbGT023AYQvPuTTJ3m2Hk9sk0gyMeQxkcjfeTjMAakk2NjuAQ4tEjpkEL1ALmwSDQTLQltyNsxNAWg4kbsOjRfIvSAv/8Q+HeQyY0w1np38gqEUaaIsdG0OOYeMMA+YEeekcAracOWNsLbstPYFNIqeY4YPBMcMN0jkFBxIMcPuFvb3H8Obbbdb28v3Ht/9I+FMjLz87ffOHDxV2cri0AAGLBJCARAcIGIBVGuBUDgLMH4CEPZwr34BT5SgYBaNgFIxQAAA4PV8ZuPVi+gAAAABJRU5ErkJggg==","orcid":"","institution":"Mountains of the University","correspondingAuthor":true,"prefix":"","firstName":"Tony","middleName":"","lastName":"Mugisa","suffix":""}],"badges":[],"createdAt":"2024-05-01 10:31:35","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4353752/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4353752/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":56542768,"identity":"3ffb299e-a5d1-41f5-87ca-689443f6e7bb","added_by":"auto","created_at":"2024-05-15 14:33:35","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":25750,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003ePrevalence of\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e \u003c/strong\u003e\u003cem\u003e\u003cstrong\u003eHuman papilloma vaccination\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4353752/v1/5299667c0273cc4cca586bec.png"},{"id":56595872,"identity":"3c87a71c-ec40-4b34-9746-51b4ada3ad13","added_by":"auto","created_at":"2024-05-16 10:29:38","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":775928,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4353752/v1/b59f713b-e6ff-4d72-9c2d-fefeeb745b89.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Factors Associated with Uptake of Human Papilloma virus Vaccine among Adolescent girls : A cross sectional survey on insights into HPV Infection Prevention in Kabarole District","fulltext":[{"header":"Highlights","content":"\u003cp\u003eGlobal Disease Burden: HPV infection is a significant global health concern, imposing a substantial disease burden.\u003c/p\u003e\n\u003cp\u003eLow HPV Vaccination Uptake: There is persistently low uptake of HPV vaccination, particularly in remote rural areas of developing countries, posing a challenge to reducing cervical cancer incidence.\u003c/p\u003e\n\u003cp\u003eStudy Objective: The study aims to assess HPV vaccine coverage among adolescents and explore determinants to improve planning in the Kabarole district.\u003c/p\u003e\n\u003cp\u003eMethodology: A cross-sectional survey was conducted among 240 adolescent girls in Kabarole district between October 2021 and February 2022. Simple and multiple logistic regression analyses were used to examine associations between HPV vaccination uptake and various factors.\u003c/p\u003e\n\u003cp\u003ePrevalence of HPV Vaccination Uptake: Overall, 63% of adolescents enrolled in the study had received the HPV vaccine.\u003c/p\u003e\n\u003cp\u003eThe factors Influencing Vaccination Uptake: HPV vaccination uptake were associated with demographics variables of the participants, respondent\u0026rsquo;s knowledge about HPV, and health system factors. Parents with secondary education were more likely to vaccinate their children. Distance from home to facility also influenced uptake, with longer distances decreasing likelihood. Moderate parental knowledge about HPV vaccination significantly increased uptake.\u003c/p\u003e"},{"header":"Introduction","content":"\u003cp\u003eHuman papilloma virus (HPV) infection has created a significant disease burden worldwide and is an important topic in public health (Kahn et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2007\u003c/span\u003e). HPV infection was the most common sexually transmitted infection (WHO, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). It was estimated that 75% of sexually active people were infected with HPV during their lifetime (Weaver et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). There are many genotypes of the HPV (Giuliano et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). HPV types 6 and 11 are the cause of 90% of cases of genital warts, whereas HPV types 16 and 18 were considered to be high-risk viruses, contributing to 70% of cases of cervical cancer(Workowski, Bolan, Centers for Disease, \u0026amp; Prevention, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; (McGuire, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2016\u003c/span\u003e)). These virus sub-types underwent cytopathology changes, causing cervical intraepithelial neoplasia, which would eventually evolve to cervical cancer after approximately 2 decades (Workowski et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). Cervical cancer is the fourth leading cause of female cancer and ranks as the second most common form of cancer globally among females aged 15 to 44 years(Workowski et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). This is in comparison with other forms of common cancers including hepatobiliary, gall bladder and bile cancers (Benson et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2017\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eA 33.6% prevalence of human papilloma virus (HPV) among women in Uganda combined with low screening uptake (Chevarie-Davis et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2013\u003c/span\u003e) had resulted in the country having one of the highest cervical cancer incidence rates in the world (Nakisige, Schwartz, \u0026amp; Ndira, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). This is attributed to a number of factors including early marriages, multiple sexual partners, multi-parity, sexually transmitted infections including HIV infection (Katz et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2013\u003c/span\u003e), tobacco use, vitamin deficiency and HPV infection (WHO, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2019\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOver 80% of diagnosed cases present with an advanced stage of the disease (Catharina J Alberts et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Cervical cancer accounted for 5.2% of the cancer burden worldwide, leading to 530 000 new cases and 270 000 deaths every year for the past decade (Chevarie-Davis et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). Apart from cervical cancer, HPV can cause precancerous lesions, ano-genital warts and other cancers of the vulva, vagina, penis, anus, and oro-pharynx (Parkin \u0026amp; Bray, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2006\u003c/span\u003e). In Uganda, cervical cancer contributes 50\u0026ndash;60% of all the female cancers and it is associated with a relative survival of approximately 20% (Banura et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2010\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA prophylactic HPV vaccine was approved and licensed in 2006 (Lechuga et al., \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2011\u003c/span\u003e), and was available since then, to prevent HPV associated infections targeting females aged 9 to 26 years (Markowitz et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). In late 2009, it was recommended that the quadrivalent HPV vaccine for males also be approved (Giuliano et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). By 2014, the Food and Drug Administration (FDA) approved another new HPV vaccine to provide additional protection against more types of HPV (Petrosky et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). Studies indicate that with an optimal coverage of about 70%, the life time risk of cervical cancer would be reduced by more than 50% (Banura et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2011\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMany countries now include the HPV vaccination in their national vaccination program(Poljak, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). As many as 19 countries in Europe (Austria, Belgium, Denmark, France, Germany, Greece, Iceland, Ireland, Italy, Latvia, Luxembourg, the Netherlands, Norway, Portugal, Romania, Slovenia, Spain, Sweden, and the United Kingdom) introduced a program of routine HPV vaccinations in 2012. Coverage rates ranged from 17\u0026ndash;84%, and 10 out of the 19 countries organized catch-up programs by May 2012 (Alberts et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). In Africa, a total of 21 developing countries including Uganda have implemented HPV vaccination projects among young girls under the support of a public-private partnership, the Global Alliance for Vaccines and Immunizations since 2013, and an estimated 206 000 girls from low-income countries were expected to benefit from these projects(Kamya et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Specifically in Uganda, the vaccine was introduced in November 2015 and rolled out to all the districts including Kabarole, and it was given to girls aged 10 years, two doses with a time interval of six months after the first dose (Bowden, Yaun, \u0026amp; Bagga, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Reiter et al., \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2011\u003c/span\u003e; )). For this study, uptake referred to completion of the two recommended doses on schedule.\u003c/p\u003e\n\u003ch3\u003eDefinition of subject matter\u003c/h3\u003e\n\u003cp\u003eThe subject matter of the article titled \"Factors Associated with Uptake of Human Papilloma virus Vaccine among Adolescent girls in Kabarole District: Insights into HPV Infection Prevention\" centers around the factors influencing the acceptance and administration of the Human Papillomavirus (HPV) vaccine among adolescent girls in the Kabarole District.\u003c/p\u003e \u003cp\u003eThe title indicates a focus on understanding the determinants affecting the adoption of the HPV vaccine among adolescent girls specifically in the Kabarole District.\u003c/p\u003e \u003cp\u003eThe objective of the study is to explore and analyze the factors associated with the uptake of the HPV vaccine among adolescent girls in Kabarole District. This involves identifying various elements that influence the decision-making process regarding HPV vaccination.\u003c/p\u003e \u003cp\u003eThe study findings provide insights into the prevention of HPV infection through vaccination. By examining the factors influencing vaccine uptake, the study contributes to understanding how to improve vaccination rates and ultimately reduce the prevalence of HPV infection and related diseases such as cervical cancer.\u003c/p\u003e \u003cp\u003eThe study aims to shed light on the determinants of HPV vaccine uptake among adolescent girls in a specific geographic area, offering valuable insights for public health policymakers, healthcare providers, and community stakeholders involved in HPV infection prevention efforts\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eSignificance of the study\u003c/strong\u003e \u003cp\u003eThe study findings were important for Kabarole district by providing insights on the factors that has led to the district failure to attain national targets for HPV vaccination. The district attainment of the national HPV vaccination targets is believed to reduce incidence of cervical cancer and other Human papilloma virus diseases among women. This will assist the district to join the rest of the world to strive for the achievement of the Sustainable Development Goal 3by reducing maternal mortality and preventable death among women.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e The study findings also provided insights on prevalence and factors leading to the low uptake of the second HPV vaccination in the district. This information is necessary to inform policy makers, health workers and community leaders to understand the causative factors for the low uptake of the HPV vaccine so that they can develop measures to increase the uptake of this very important vaccine.\u003c/p\u003e \u003cp\u003eBy identifying the associated factors to the low uptake of HPV vaccine, recommendations have been developed to support the district and health facilities within the district to implement blended strategies that can lead to improvement in the uptake of the HPV vaccine.\u003c/p\u003e \u003cp\u003eOther researchers will use information as baseline to develop proposals for studies in this area and find out more about the HPV vaccination. the study findings can also improve ministry of health planning to address the HPV vaccine uptake problem and hence reduce the prevalence of cervical cancer in the county.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eStudy objectives\u003c/strong\u003e \u003cp\u003eThe study aim was to determine the uptake of human papilloma virus vaccine and associated factors among adolescent girls in Kabarole district.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eThe study achieved its aim using the following objectives:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTo determine the uptake of Human papilloma virus vaccine coverage among adolescent girls aged 11 to 15 years in Kabarole district.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTo establish the socio-demographic and socio-economic factors associated with the uptake of Human papilloma virus vaccine among adolescent girls aged 11 to 15 years in Kabarole district.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTo establish the health system factors associated with the uptake of Human Papilloma virus vaccine among adolescent girls aged 11 to 15years in Kabarole district.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eby achieving the above objectives the study aimed to answer the following questions:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWhat was the level of uptake of Human papilloma virus vaccine among adolescent girls aged 11to 15 years in Kabarole District?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWhat are socio-demographic and socio economic factors associated with the uptake of the Human papilloma virus vaccine among adolescent girls aged 11 to 15 years in Kabarole District?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWhat are the health system factors associated with the uptake of Human Papilloma virus vaccine among adolescent girls aged 11 to 15years in Kabarole district.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design, Setting and Procedures\u003c/h2\u003e \u003cp\u003eBetween December 2017 and July 2018, we conducted a A cross-sectional study design employing both quantitative and qualitative research methods was used. The study was done in Kabarole District, which was one of the districts in Uganda where this programme was first rolled out in the country in 2015. The district is located in Western regiion of Uganda, about 300 km from the city center of Kampala. The district is bordered by Bunyangabu district in the West, Kamwenge in the South, Kyenjojo in the East, Bundibugyo and Ntoroko in the North and by Kibaale in the Northeast.\u003c/p\u003e \u003cp\u003eThe district had 38 health facilities. In terms of level of facility, the district has 4 hospitals, 2 health sub districts, 18 health center IIIs and 14 Health center IIs and all facilities conduct HPV vaccination at both static and outreach sites. The district is made up of two counties that is Burahya county and Fort portal Tourism city. The district is further subdivided into 11sub counties, 4 town councils and 3 divisions (total of 18). According to UBOS report on population survey (2017), Kabarole district has an estimated total population of 302,923 people.\u003c/p\u003e \u003cp\u003eThe target population was adolescent female girls aged between 11 to 15 years, because they are in the age bracket of those who should have completed the Human papilloma virus vaccination schedule by the time of the study since the national rollout of the vaccination programme in 2015. For each adolescent girl, the caretaker was interviewed to get the caretaker related factors.\u003c/p\u003e \u003cp\u003eThe immunization focal person or in charge of the corresponding health facility in the selected sub county was engaged in a key informant interview.\u003c/p\u003e \u003cp\u003eThe study involved multistage sampling. This method was considered appropriate because the population was large and widely scattered in the district. The primary sampling unit (PSU) was the district considered as the first sampling stage. The secondary sampling unit (SSU) were the sub-counties as the second sampling stage, parishes as the third sampling stage, households as the fourth sampling stage and then further sampling of individuals within each household selected as the fifth secondary sampling unit. From each sub county, one parish was selected by simple random sampling, where all the parishes were given numbers. The villages in each parish were be selected randomly using simple random sampling from the list of villages registered at the sub county. A total of eight (8) villages were selected. A proportion to size was used to select households and then systemic random sampling method were used. A list of households in the selected villages having adolescent girls aged between 11 and 15 years was generated using information from the village health teams. The design effect of 1.106 was factored in computation of the sample size. The sample size adjusted for design effect was 240 young girls.\u003c/p\u003e \u003cp\u003eFor key informant interviews, 6 EPI focal persons or the in charge of a health facility which was in the selected sub county was also interviewed using a prepared checklist.\u003c/p\u003e \u003cp\u003e \u003cb\u003eMeasurement of Knowledge about HPV vaccination.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eKnowledge about HPV vaccination by both the adolescent girl and the caretaker was measured using the ten standard questions in section 2 of the respective tools. Those who answered correctly any nine of the questions were considered to have high knowledge, those who answered any five questions were considered to have moderate knowledge and those who answered any four or less questions were considered to have low knowledge. These questions in the tools were tested and had a content validity index of 0.76 from two experts.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eData Collection\u003c/h2\u003e \u003cp\u003eQuantitative data was collected by interviews using an interviewer administered semi structured questionnaire. The data included the social demographic factors, knowledge about HPV vaccination and uptake. The adolescent girls were asked whether they have received the HPV vaccine and the number of doses with evidence and those without evidence were considered not vaccinated. The caretaker of the adolescent girl was interviewed using a separate interview guide. A content validity index of 0.76 was obtained from two experts. The questionnaires were pretested on 10 adolescent girls in a nearby village before the final use for the study. A Cronbach's alpha of 0.79 was obtained. Qualitative data were collected from key informants using a key informant\u0026rsquo;s guide and the audios recorded. Data was collected between October 2021 and February 2022 ADDIN ZOTERO_ITEM CSL_CITATION {\"citationID\":\"T0PN5Odc\",\"properties\":{\"formattedCitation\":\"(Nabirye et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2020\u003c/span\u003e)\",\"plainCitation\":\"(Nabirye et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2020\u003c/span\u003e)\",\"noteIndex\":0},\"citationItems\":[{\"id\":516,\"uris\":[\"\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://zotero.org/users/13672379/items/6IP77YV7\"],\"itemData\":{\"id\":516,\"type\":\"article-journal\",\"abstract\":\"In\u003c/span\u003e\u003cspan address=\"http://zotero.org/users/13672379/items/6IP77YV7\u0026quot;],\u0026quot;itemData\u0026quot;:{\u0026quot;id\u0026quot;:516,\u0026quot;type\u0026quot;:\u0026quot;article-journal\u0026quot;,\u0026quot;abstract\u0026quot;:\u0026quot;In\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e the original article [1] the first paragraph of the Background section was omitted due to a discrepancy between the metadata of the article and the PDF version.\",\"container-title\":\"BMC Public Health\",\"DOI\":\"\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12889-020-8348-y\",\"ISSN\":\"1471\u0026ndash;2458\",\"issue\":\"1\",\"journalAbbreviation\":\"BMC\u003c/span\u003e\u003cspan address=\"10.1186/s12889-020-8348-y\u0026quot;,\u0026quot;ISSN\u0026quot;:\u0026quot;1471\u0026ndash;2458\u0026quot;,\u0026quot;issue\u0026quot;:\u0026quot;1\u0026quot;,\u0026quot;journalAbbreviation\u0026quot;:\u0026quot;BMC\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e Public Health\",\"language\":\"en\",\"page\":\"491\",\"source\":\"DOI.org(Crossref)\",\"title\":\"Correction to: Health system factors influencing uptake of human papilloma virus (HPV) vaccine among adolescent girls 9\u0026ndash;15 years in Mbale District, Uganda\",\"title-short\":\"Correction to\",\"volume\":\"20\",\"author\":[{\"family\":\"Nabirye\",\"given\":\"Juliet\"},{\"family\":\"Okwi\",\"given\":\"Livex Andrew\"},{\"family\":\"Nuwematsiko\",\"given\":\"Rebecca\"},{\"family\":\"Kiwanuka\",\"given\":\"George\"},{\"family\":\"Muneza\",\"given\":\"Fiston\"},{\"family\":\"Kamya\",\"given\":\"Carol\"},{\"family\":\"Babirye\",\"given\":\"Juliet N.\"}],\"issued\":{\"date-parts\":[[\"2020\",12]]}}}],\"schema\":\"\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://github.com/citation-style-language/schema/raw/master/csl-citation.json\"\u003c/span\u003e\u003cspan address=\"https://github.com/citation-style-language/schema/raw/master/csl-citation.json\u0026quot;\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e} (Nabirye et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2020\u003c/span\u003e)(Muellmann et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eMeasurement of key study variables\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eDependent variables\u003c/strong\u003e \u003cp\u003eThe dependent variable for this study were uptake of Human papilloma virus vaccine (HPV) which was classified into fully vaccinated and not fully vaccinated, where fully vaccination means having taken all the two doses on time or schedules as evidenced by the child vaccination card or a recall of receiving two doses of the vaccine on the left upper arm.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eIndependent variables\u003c/strong\u003e \u003cp\u003eThese included individual factors such as knowledge and perception of the adolescent girls and parents/caretakers, socio-demographics, cultural factors, and health facility factors, such as availability of the HPV vaccination services in the health facilities, mode of service delivery like health facility based or outreach based, consistency of the vaccination services at the health facilities, availability of the required equipment\u0026rsquo;s for HPV vaccination at the health facilities.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData Management and Statistical Analysis\u003c/h2\u003e \u003cp\u003eData collected from the questionnaires were inspected for errors and gaps. After inspection and editing, it was entered into excel version 12. Questions were coded and analyzed using STATA version 15.\u003c/p\u003e \u003cp\u003eData were entered and verified in Ms-Excel and exported to. Stata 15 software. Stata Corporation, College Station, USA was used for analyses.\u003c/p\u003e \u003cp\u003eThe data was analyzed at three different levels; univariate, bivariate and multivariate using the binary logistic regression model.\u003c/p\u003e \u003cp\u003eBivariate associations were done to test any possible associations between each of the independent variables and the dependent variable. Statistical significance of the relationships was determined for the P-value (P\u0026thinsp;\u0026lt;\u0026thinsp;0.2) and all significant variables at this level were considered at multivariate level of analysis.\u003c/p\u003e \u003cp\u003eMultivariate analysis was performed to assess which factor was associated with the uptake of HPV vaccination more than the other. The HPV was classified into fully vaccinated and not fully vaccinated. Thus HPV vaccination is a nominal (Binary/dichotomous) variable and therefore the suitable model to analyze this kind of criterion variable is the binary logistic regression. Binary logistic regression analysis was used because it attempts to control for possible confounding effect of independent variables on each other and thus finds the independent association for each predictor variable with the criterion variable (Kirkwood, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e1981\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFor qualitative data, audio tape recordings were transcribed verbatim, coded and uploaded in the qualitative data analysis software MAXQDA version 12 for analysis. Cut and paste approach was used for best quotes to triangulate quantitative information as best quotes.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eEthics\u003c/h2\u003e \u003cp\u003e The study was approved by the research and ethics committee of Mbarara University of science and technology and by the Uganda National Council for Science and Technology.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eof the 240 caretakers of female adolescents aged 11 to 15 years in Kabarole district enrolled into the study, the majority were Batoro, 153(65.7%), married/cohabiting, 140 (52.6%), residing in a rural setting, 152 (66.3%) and 229 (95.4%) earned a net income less than 100,000 Uganda shillings. The mean age for parents/caregivers was 38.53 (SD\u0026thinsp;=\u0026thinsp;8.75) years (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHPV vaccination coverage was at 62.5% (n\u0026thinsp;=\u0026thinsp;150),95% CI (0.562\u0026ndash;0.684) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMultivariate analysis was performed to assess which factors were associated with uptake of human papilloma virus vaccine. Binary logistic regression model was used since the outcome variable was binary/dichotomous. At a multivariate level, all factors which had p-values below the threshold of 0.2 at the bivariate analysis were included in the multivariate model (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). A reference category was selected for each categorical variable.\u003c/p\u003e \u003cp\u003eThe multivariate analysis showed that parents who completed secondary level of education were 4.1 times more likely to take their children for HPV vaccination compared to parents whose education level was primary or had no formal education Adjusted Odds Ratio (AOR) (AOR\u0026thinsp;\u003cb\u003e=\u003c/b\u003e\u0026thinsp;4.06; 95%CI (1.69\u0026ndash;6.87\u003cb\u003e);\u003c/b\u003e p\u0026thinsp;=\u0026thinsp;0.004). Furthermore, distance from home to facility where the services of HPV vaccination were, was also associated with uptake HPV vaccination. Participants who came from the distance of more than 5 km were 60% less likely to uptake HPV vaccination compared to those who come from 5km or less (AOR\u0026thinsp;=\u0026thinsp;0.4; 95%CI (0.34\u0026ndash;0.89); p\u0026thinsp;=\u0026thinsp;0.006). The multivariate analysis further revealed that parents whose knowledge about HPV vaccination was moderate were three times more likely to take up HPV vaccine compared to those whose knowledge was low (AOR\u0026thinsp;=\u0026thinsp;2.99; 95%CI (1.14\u0026ndash;7.87); p\u0026thinsp;=\u0026thinsp;0.026).\u003c/p\u003e \u003cp\u003eOther factors like tribe of caregiver, age of parent, impact of Religion on child HPV vaccination, and impact of clan on child HPV were not significantly associated with uptake of human papilloma virus vaccine at multivariate analysis.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSocio-demographic characteristics of the respondents (N\u0026thinsp;=\u0026thinsp;240)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003en(%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge (years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c4\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdolescent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c4\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eMean\u0026thinsp;=\u0026thinsp;12.71, SD\u0026thinsp;=\u0026thinsp;1.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e107(44.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c4\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13\u0026ndash;15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e133(55.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c4\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eAge (years) caretaker\u003c/p\u003e \u003cp\u003eMean\u0026thinsp;=\u0026thinsp;38.53, SD\u0026thinsp;=\u0026thinsp;8.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25\u0026ndash;34 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e79 (32.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c4\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35\u0026ndash;44 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e117 (48.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c4\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;44 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e44 (18.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c4\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eEducation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026le;Primary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e215(90.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c4\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23(23.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c4\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eGender of the caretaker\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e109(45.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c4\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e131(54.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c4\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eEducation Adolescent\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026le;Primary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e136(57.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c4\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e102(42.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c4\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eTribe of Adolescent\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMutoro\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e153 (65.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c4\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e87 (36.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c4\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eReligious affiliation of caretaker\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAnglican\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e82 (34.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c4\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCatholic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e114 (47.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c4\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e44 (18.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c4\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003eMarital status of caretaker\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e68 (28.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c4\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMarried/cohabiting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e130 (54.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c4\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCohabiting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18 ( 7.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c4\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWidowed/\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6 ( 2.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c4\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDivorced/separated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18 ( 7.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c4\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eResidence\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e152 (66.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c4\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e88 (36.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c4\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eOccupation of caretaker\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e110 (46.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c4\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePeasant/Farmer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e108 (45.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c4\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBusiness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22 ( 9.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c4\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eAverage monthly income (Ugandan shillings) of caretaker\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;100,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e229 (95.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c4\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;100,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11 ( 4.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c4\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMultivariate analysis results of factors associated with the uptake of Human papilloma virus vaccine among adolescent girls aged 11 to 15 years in Kabarole district (n\u0026thinsp;=\u0026thinsp;240)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eAOR 95%CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP_value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation of caretaker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary/no formal education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost-Secondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003e4.06(1.69\u0026ndash;6.87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.004**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTribe of caretaker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMutoro\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003e1.13 (0.47\u0026ndash;2.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.789\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDistance from home to facility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;5km\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;5km\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003e0.4 (0.34\u0026ndash;0.89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.006**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge of caretaker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;35 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e35\u0026ndash;44 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003e0.93(0.37\u0026ndash;2.35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.875\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;44 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003e0.70(0.23\u0026ndash;2.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.529\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHPV knowledge of caretaker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003e2.99 (1.14\u0026ndash;7.87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.026**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003e2.21 (0.86\u0026ndash;5.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.102\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImpact of Religion on child HPV vaccination\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003e0.61(0.18\u0026ndash;2.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.418\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImpact of clan on child HPV vaccination\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003e0.57(0.17\u0026ndash;1.95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.374\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003e**Statistical significant (p ≤ 0.05) at multivariate analysis\u003c/h3\u003e\n"},{"header":"Discussion","content":"\u003cp\u003eThis household-based cross-sectional study among adolescent females aged 11 to 15 years in Kabarole district, HPV vaccination coverage was at 63%. Uganda Ministry of Health reported an annualized HPV coverage of 85% for HPV 1 and as low as 41% (Patrick et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2022\u003c/span\u003e)for HPV 2 as of December 2017(WHO \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). In Kabarole district, they reported high HPV1 vaccine coverage at 114%, but still very low HPV2 vaccine coverage at 51% in 2017 (Ministry of Health 2017), HPV1 at 110% and HPV2 at 50% in 2018 (Ministry of Health 2018) and HPV 1 at 91% and HPV2 at 64% in 2019 (Ministry of Health 2019) this is in line with the findings from the study by Chuang et al who concluded that efforts to improve HPV initiation and completion could benefit from additional attention to factors at the health care (Chuang et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). According to a study carried out in Soweto South Africa, of 224 adolescents recruited, 201 initiated the vaccine; 192 (95.5%) received a second immunization; and 164 (81.6%) completed three doses. In that qualitative study, of 39 adolescent-caregivers, it was found out that factors driving vaccine uptake reflected a socio-cultural backdrop of high HIV endemnicity, sexual violence, poverty, and an abundance of female-headed households (Katz et al. \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Bair et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2008\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFindings from a study by Migoneetal, HPV vaccine uptake in Ireland was high. Even in schools that are disadvantaged, HPV was above the national target of 80%. Since then, anti-HPV vaccine publicity has had a negative impact on national HPV vaccine uptake in Irish schools. The study also found out that even notwithstanding recent anti- HPV vaccine publicity, school-based programmes, such as the Irish HPV vaccination programme have been shown to maximize uptake of vaccines when compared with opportunistic community based programmes (Kessels et al., \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2012\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe study by Migoneetal, demonstrates that inequity in uptake may persist in school based programmes while the difference in mean and median uptake between disadvantaged schools and other Irish schools in Irish study was small, the majority of schools with the lowest uptake (\u0026le;\u0026thinsp;50%) were disadvantaged. Disadvantaged schools were twice as likely to have an uptake of \u0026le;\u0026thinsp;50% when compared with other schools, independent of other school characteristics (Kessels et al., \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2012\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eLower HPV vaccine uptake in disadvantaged schools has been reported by other studies; In Manchester, uptake was significantly lower in more deprived areas while in Ontario, Canada, uptake of HPV vaccine in schools was lower in girls from lower income backgrounds (Fisher et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2014\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFindings from a longitudinal study carried out in Eldoret, Kenya, where HPV vaccine acceptability was measured before a vaccination program (n = 287) and vaccine uptake, as reported by mothers, once the program was finished (n = 256) indicates that even though baseline acceptance was very high (88.1%), only 31.1% of the women reported at follow-up that their daughters had been vaccinated. The vaccine was declined by 17.7%, while another 51.2% had wanted the vaccination but were obstructed by practical barriers including cultural acceptance related barriers (Joseph et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Vermandere et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2014\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA study conducted in Lira district, Uganda, on the level and factors associated with the uptake of HPV vaccine among adolescent girls aged between 12 and 17 years also demonstrated low uptake where 49.6%(228/460) had not taken any of the vaccines, 18%(83/460) had received one dose, 14.8%(68/460) had received two doses and the uptake was associated with factors like education and other social economic factors (Kisaakye et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Isabirye et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) .\u003c/p\u003e \u003cp\u003eKnowledge of HPV vaccination and distance to facility were the factors associated with uptake of Human papilloma virus vaccine among adolescent girls aged 11 to 15 years in Kabarole district.\u003c/p\u003e \u003cp\u003eBaseline information on knowledge, attitude and practice towards HPV vaccination was crucial in establishing a progress track on the current HPV immunization program (Jalani et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). In a study conducted in Malaysia with a total sample of 380 respondents who participated in this study. Females scored significantly higher for the knowledge \u003cb\u003ei\u003c/b\u003etems compared to the males. Majority of respondents (86.6%) indicated their intention to get HPV vaccines. Willingness to be vaccinated was significantly associated with the level of knowledge of cervical cancer (AOR 1.66; 95% CI 1.018\u0026ndash;2.698; p\u0026thinsp;=\u0026thinsp;0.042). Gender (AOR 3.29; 95% CI 2.00-5.41; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) lack of knowledge was found to be a significant predictor for someone who rejects vaccination due to side effects (Jalani et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2019\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe study conducted by Satterwhite CL in Malaysia concluded that knowledge of HPV and its preventive measures among the respondents were still insufficient. Attitude towards HPV vaccination was significantly associated with knowledge about cervical cancer (Lechuga et al., \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). In addition, vaccination practice among secondary school girls was high, indicating that the national HPV immunization program was effective in delivering the HPV vaccine (Satterwhite et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2013\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSince acceptance of HPV vaccination varies internationally, and many adolescents were still not getting the HPV vaccine in various countries (Wigle et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2013\u003c/span\u003e), it was important to understand why some parents choose to vaccinate their children and some parents do not in order to continue to increase vaccination uptake. According to the study conducted by Brooke Nickel 2017, both low and high HPV knowledge may be associated with lower rates of vaccination, with parents' country and gender also being influential factors. It also demonstrated that parental attitudes towards the HPV vaccine differ by country and knowledge (Nickel et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2017\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eGiven that the primary target population for HPV vaccination program was girls aged 9\u0026ndash;13, typically before the initiation of sexual accident, parental knowledge and attitudes play an important role in the success of vaccination as consent was usually required for their adolescent children to be vaccinated. Research aimed at understanding HPV vaccine uptake has demonstrated that uptake of the HPV vaccine was generally high with good knowledge about the vaccine, however parents and girls often had insufficient knowledge and understanding about and had varying attitudes towards vaccination (Hendry et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). Alongside this, several studies conducted across different settings have aimed to examine factors influencing HPV vaccine uptake. Findings from these studies were wide-ranging, however, parental intentions have been shown to consistently be a strong predictor of their children's HPV vaccine uptake (C. J. Alberts et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2017\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAccording to the findings by Brooke 2017, the strongest factor associated with daughters' vaccination status across the entire sample was parents' HPV knowledge (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Parents' HPV knowledge scores displayed a non-linear relationship; parents with low knowledge scores and parents with high knowledge scores were less likely to have vaccinated their daughters. HPV vaccination specific knowledge was also significant univariate factor associated with vaccination status (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) (Hendry et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2013\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eVaccination specific knowledge and very high levels of vaccination specific knowledge were also less likely to have vaccinated their daughters. Parents' demographic characteristics including their country of origin (OR\u0026thinsp;=\u0026thinsp;2.2, 95% CI: 1.07\u0026ndash;4.50; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) and gender (OR\u0026thinsp;=\u0026thinsp;0.5 95% CI: 0.26\u0026ndash;0.94, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) were also factors associated with non-vaccination, with parents in the US and men (across all countries) being less likely to vaccinate their daughters (Kessels et al., \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2012\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThis is also in line with a study conducted in Ethiopia Debre Tabar Town by Gedefaye in which secondary education and above (AOR 1.70, 95% CI 1.05\u0026ndash;2.27) and having good knowledge of the HPV vaccine (AOR 3.30, 95% CI 2.21\u0026ndash;4.93) were significantly associated with willingness to receive the HPV vaccine.\u003c/p\u003e \u003cp\u003eFrom the qualitative analysis, it was reported that some villages in Kabende are hard to reach and it is worse in the rainy season when the road network is poor. This is consistent with the findings on the quantitative analysis where long distance to the health facilities (Nabirye et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) was associated with poor uptake of the vaccination. The long distance with a poor road network makes it hard for the adolescents to access the vaccination points (Kessels et al., \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2012\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn Summary, the findings in this study are consistent with the results in other studies where the uptake and completion of the vaccination programme is still a challenge (Joseph et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2012\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAlso the findings on the factors associated with the uptake from this study are consistent with the findings in other studies where knowledge about the vaccine by both the adolescent girl and caretaker, level of education by the caretaker and accessibility to the vaccination points are strongly associated with uptake of the vaccine (Kahn et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2007\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFrom this study, it was also established that most HPV vaccination programmes target girls aged less than 12 years old or those in primary school, which enables them to get the best protection. Most girls at secondary school level have already started sexual debut, so it is very important for them to complete the HPV vaccination before they start secondary education(Whelan, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2016\u003c/span\u003e).\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, this study provides a preliminary insight into the uptake of human papillomavirus vaccine among adolescent girls in Kabarole district. HPV vaccination uptake was at 63% and relatively lower than national average. Education of caretaker, Knowledge of HPV vaccination and distance to facility were the factors associated with uptake of Human papilloma virus vaccine among adolescent girls aged 11 to 15 years in Kabarole district.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCacx: Cancer of the cervix\u003c/p\u003e\n\u003cp\u003eCI: Confidence Interval\u003c/p\u003e\n\u003cp\u003eELISA: Enzyme Linked Immune Absorbent Assays\u003c/p\u003e\n\u003cp\u003eFREC: Faculty Research and Ethics Committee\u003c/p\u003e\n\u003cp\u003eHCIII: Health Center Three\u003c/p\u003e\n\u003cp\u003eHIV: Human Immune Virus\u003c/p\u003e\n\u003cp\u003eHMIS:\u0026nbsp;Health Management Information Systems\u003c/p\u003e\n\u003cp\u003eHPV: Human papilloma virus\u003c/p\u003e\n\u003cp\u003eHPV 1: Human papilloma virus vaccine first dose\u003c/p\u003e\n\u003cp\u003eHPV 2: Human papilloma virus vaccine second dose\u003c/p\u003e\n\u003cp\u003eMoH: Ministry of Health\u003c/p\u003e\n\u003cp\u003eMUST:\u0026nbsp;Mbarara University of Science and Technology\u003c/p\u003e\n\u003cp\u003ePCR: Polymerase Chain Reaction\u003c/p\u003e\n\u003cp\u003eRDTs:\u0026nbsp;Rapid Diagnostic Test\u003c/p\u003e\n\u003cp\u003eREC: Research and Ethics Committee\u003c/p\u003e\n\u003cp\u003eUDHS:\u0026nbsp;Uganda Demographic Health Surveys\u003c/p\u003e\n\u003cp\u003eUBOS: Uganda Bureau of Statistics\u003c/p\u003e\n\u003cp\u003eUGX:\u0026nbsp;Uganda Shillings\u003c/p\u003e\n\u003cp\u003eVHT: Village Health Team\u003c/p\u003e\n\u003cp\u003eWHO: World Health Organization\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNorm/Standard according to which research was conducted:\u0026nbsp;\u003c/strong\u003eThis research was conducted adhering to\u0026nbsp;\u0026nbsp;guidelines set forth by the Declaration of Helsinki, which outlines ethical principles for medical research involving human subjects. The\u0026nbsp;\u0026nbsp;research was approved by \u0026nbsp;the Research and Ethics committee of the Faculty of Medicine of Mbarara University of science and technology, and to the research and ethics committee of Mbarara University of science and technology.\u003c/p\u003e\n\u003cp\u003eThe study protocol was aligned with ethical guidelines. Informed consent was obtained from \u0026nbsp;study participants and their guardians, Participants in the study were ensured of confidentiality of their data, minimization of potential harm and discomfort, and respect for participant autonomy and dignity\u0026nbsp;was maintained.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAdditionally, the study adhered to relevant national and institutional regulations regarding research involving human subjects and disclosed any potential conflicts of interest. \u0026nbsp;Authorization to carry out the study was obtained from the health sub district authorities, education officer, and the district health office authorities in the study area. More so authorization to interview health workers was obtained from their facility managers before they could participate in the study. The objectives of the study were explained to study participants and/or their guardians and written consent was obtained when consented to participlate in the study. The consent form was signed in duplicate, and one copy remained with the participant. To ensure privacy and confort to the participants, participant were interviewed from a selected private place at their home, workplace or school. All participants in the study were assured that they were free to pull out of the study in case they feel uncomfortable and that no consequences at all were to be gotten for the respondents who decide to move out of the study. The respondents were told that no names were required as the information given was solely for academic research purposes.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll the authors of this manuscript were fully consulted and all do consent to publish this article\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have declared that there are no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e The research was not sponsored by any government or agency\u003c/p\u003e\n\u003cp\u003eORCID iDs: Tony Mugisa, Dip CM, BSc PH, MPH iD :\u0026nbsp;\u0026nbsp;\u003ca href=\"https://orcid.org/0009-0008-9559-1179\" target=\"https://mail.yahoo.com/d/search/name=ORCID\u0026emailAddresses=donotreply%2540verify.orcid.org\u0026listFilter=ALL\u0026contactIds=9a16.0a49/messages/_blank\"\u003ehttps://orcid.org/0009-0008-9559-1179\u003c/a\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSA, \u0026nbsp; and\u0026nbsp;TM conceptualized the research work, TM and SA conducted\u0026nbsp;Data collection, Data analysis\u0026nbsp;and drafted the manuscript,\u0026nbsp;SA, FNB, and TM did final revision; SA, FNB and TM Read and approved final manuscript. SA, FNB, and TM\u0026nbsp;reviewed and approved the manuscript, and also conducted the literature search.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; abbreviations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSA: Solomon Asiimwe; TM: Tony Mugisa; FNB:\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eFred Norman Bagenda\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ethe Authors thank the research assistants for their integrity and hard work in collecting the data, the teachers of the participating schools for their cooperation and the health workers who provided valuable information for this study. The authors also acknowledge all researchers whose findings helped in the development of this manuscript. The Authors also thank\u0026nbsp;all the study participants-\u0026nbsp;adolescent girls in Kabarole district,\u0026nbsp;for accepting to participate in the study.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors and Affiliations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDepartment of Post Public Health, Faculty of Health Sciences, Mountains of the Moon University, Fort Portal City, Uganda\u003c/p\u003e\n\u003cp\u003eTony Mugisa\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDepartment of Community Health, Faculty of Health sciences, Mbarara \u0026nbsp; University of Science and Technology, Mbarara City, Uganda\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSolomon Asiimwe and Authors and Affiliations\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCorresponding author\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTony Mugisa\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBanura, C., Mirembe, F. 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Sociodemographic Factors Associated With High-Risk Human Papillomavirus Infection. \u003cem\u003eObstetrics \u0026amp; Gynecology\u003c/em\u003e, \u003cem\u003e110\u003c/em\u003e(1), 87\u0026ndash;95. https://doi.org/10.1097/01.AOG.0000266984.23445.9c\u003c/li\u003e\n\u003cli\u003eKatz, I. T., Nkala, B., Dietrich, J., Wallace, M., Bekker, L.-G., Pollenz, K., Bogart, L. M., Wright, A. A., Tsai, A. C., Bangsberg, D. R., \u0026amp; Gray, G. E. (2013). A Qualitative Analysis of Factors Influencing HPV Vaccine Uptake in Soweto, South Africa among Adolescents and Their Caregivers. \u003cem\u003ePLoS ONE\u003c/em\u003e, \u003cem\u003e8\u003c/em\u003e(8), e72094. https://doi.org/10.1371/journal.pone.0072094\u003c/li\u003e\n\u003cli\u003eKessels, S. J. M., Marshall, H. S., Watson, M., Braunack-Mayer, A. J., Reuzel, R., \u0026amp; Tooher, R. L. (2012). Factors associated with HPV vaccine uptake in teenage girls: A systematic review. \u003cem\u003eVaccine\u003c/em\u003e, \u003cem\u003e30\u003c/em\u003e(24), 3546\u0026ndash;3556. https://doi.org/10.1016/j.vaccine.2012.03.063\u003c/li\u003e\n\u003cli\u003eKirkwood, B. R. (1981). Chi-square test for contingency tables. \u003cem\u003eBritish Journal of Hospital Medicine\u003c/em\u003e, \u003cem\u003e25\u003c/em\u003e(3), 291\u0026ndash;292.\u003c/li\u003e\n\u003cli\u003eLechuga, J., Swain, G. R., \u0026amp; Weinhardt, L. S. (2011). The Cross-Cultural Variation of Predictors of Human Papillomavirus Vaccination Intentions. \u003cem\u003eJournal of Women\u0026rsquo;s Health\u003c/em\u003e, \u003cem\u003e20\u003c/em\u003e(2), 225\u0026ndash;230. https://doi.org/10.1089/jwh.2010.1993\u003c/li\u003e\n\u003cli\u003eMcGuire, S. (2016). World Cancer Report 2014. Geneva, Switzerland: World Health Organization, International Agency for Research on Cancer, WHO Press, 2015. \u003cem\u003eAdvances in Nutrition\u003c/em\u003e, \u003cem\u003e7\u003c/em\u003e(2), 418\u0026ndash;419. https://doi.org/10.3945/an.116.012211\u003c/li\u003e\n\u003cli\u003eMuellmann, S., Brand, T., J\u0026uuml;rgens, D., Gansefort, D., \u0026amp; Zeeb, H. (2021). How many key informants are enough? Analysing the validity of the community readiness assessment. \u003cem\u003eBMC Research Notes\u003c/em\u003e, \u003cem\u003e14\u003c/em\u003e(1), 85. https://doi.org/10.1186/s13104-021-05497-9\u003c/li\u003e\n\u003cli\u003eNabirye, J., Okwi, L. A., Nuwematsiko, R., Kiwanuka, G., Muneza, F., Kamya, C., \u0026amp; Babirye, J. N. (2020). Correction to: Health system factors influencing uptake of human papilloma virus (HPV) vaccine among adolescent girls 9\u0026ndash;15 years in Mbale District, Uganda. \u003cem\u003eBMC Public Health\u003c/em\u003e, \u003cem\u003e20\u003c/em\u003e(1), 491. https://doi.org/10.1186/s12889-020-8348-y\u003c/li\u003e\n\u003cli\u003ePatrick, L., Bakeera-Kitaka, S., Rujumba, J., \u0026amp; Malande, O. O. (2022). Encouraging improvement in HPV vaccination coverage among adolescent girls in Kampala, Uganda. \u003cem\u003ePLOS ONE\u003c/em\u003e, \u003cem\u003e17\u003c/em\u003e(6), e0269655. https://doi.org/10.1371/journal.pone.0269655\u003c/li\u003e\n\u003cli\u003eReiter, P. L., McRee, A.-L., Gottlieb, S. L., \u0026amp; Brewer, N. T. (2011). Correlates of receiving recommended adolescent vaccines among adolescent females in North Carolina. \u003cem\u003eHuman Vaccines\u003c/em\u003e, \u003cem\u003e7\u003c/em\u003e(1), 67\u0026ndash;73. https://doi.org/10.4161/hv.7.1.13500\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Papilloma virus, HPV, Adolescent, Human papilloma virus (HPV), Vaccination uptake, Adolescent girls, Kabarole district, Demographics, Knowledge Health system factors, Logistic regression, Prevalence, Education level, Distance to facility, Cervical cancer, Disease burden, Public health, Rural areas","lastPublishedDoi":"10.21203/rs.3.rs-4353752/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4353752/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground: Human papilloma virus (HPV) infection imposes a substantial global disease burden and represents a critical public health concern. The persistently low uptake of HPV vaccination poses a significant obstacle to reducing cervical cancer incidence, particularly in remote rural areas of developing nations.\u003c/p\u003e\n\u003cp\u003eObjective: This study aims to assess the extent of Human papilloma virus vaccine coverage among adolescents and explore the associated determinants to facilitate enhanced planning strategies within the Kabarole district.\u003c/p\u003e\n\u003cp\u003eMethodology: Employing a cross-sectional survey approach, data were gathered from 240 adolescent girls residing in the Kabarole district between October 2021 and February 2022. Simple and multiple logistic regression analyses were employed to investigate the relationships between HPV vaccination uptake and various independent variables, including demographics, HPV knowledge, and health system factors.\u003c/p\u003e\n\u003cp\u003eResults : Of the 240 adolescents enrolled, the overall prevalence of uptake of HPV vaccination was 63%. The uptake of human papilloma was associated with demographics knowledge about HPV and health systems factors. The multivariate analysis showed that parents who completed secondary level of education were 4.1 times more likely to take their children for HPV vaccination compared to parents whose education level was primary or had no formal education(AOR=4.06; 95%CI(0.69-0.087); p=0.004). Distance from home to facility was associated with uptake HPV vaccination. Participants who came from the distance of more than 5 km were 60% less likely to uptake HPV vaccination compared to those who come from 5km or less (OR=0.4; 95%CI (1.43 – 8.09); p=0.006). Results further revealed that parents whose knowledge about HPV vaccination was moderate were three times more likely to take up HPV vaccine compared to those whose knowledge was low (OR = 2.99; 95%CI(1.14 – 7.87); p=0.026).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003cem\u003e \u003c/em\u003e: HPV vaccination uptake was at 63% and relatively lower than national average. Education of parents, Knowledge of HPV vaccination and distance to facility were factors significantly associated with uptake of Human papilloma virus vaccine\u003c/p\u003e","manuscriptTitle":"Factors Associated with Uptake of Human Papilloma virus Vaccine among Adolescent girls : A cross sectional survey on insights into HPV Infection Prevention in Kabarole District","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-05-15 14:33:30","doi":"10.21203/rs.3.rs-4353752/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8a38376b-a57c-4e11-b270-9852e1c1c37d","owner":[],"postedDate":"May 15th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-05-16T10:21:31+00:00","versionOfRecord":[],"versionCreatedAt":"2024-05-15 14:33:30","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4353752","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4353752","identity":"rs-4353752","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}