Designing for insight. A Mixed-Methods Approach to Unpacking HPV Vaccine Uptake in Rural Uganda

Designing for insight. 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A Mixed-Methods Approach to Unpacking HPV Vaccine Uptake in Rural Uganda Mbonigaba Rukarama Evarist, Ronald Arineitwe Kibonire This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7444969/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background Low uptake of the Human Papillomavirus (HPV) vaccine series presents a persistent challenge in preventing cervical cancer in low-resource settings like Uganda. Effective interventions rely on a nuanced understanding of contributing factors. This paper outlines the comprehensive mixed-methods research approach and cross-sectional design employed to investigate factors associated with low HPV vaccine uptake among adolescent girls in Rukiga District, Uganda. Methods A convergent mixed-methods, cross-sectional design was utilized integrating quantitative and qualitative data collected concurrently between September and November 2022. The study involved 292 caregivers of adolescent girls and 21 key informants (health workers and Village Health Team members) in Rukiga District. A multi-stage sampling technique ensured representativeness for quantitative data. Quantitative data collected via semi-structured questionnaires were analyzed using descriptive statistics, bivariate analysis, and multivariable logistic regression in SPSS. Qualitative data, gathered through in-depth interviews, underwent thematic analysis. Robust measures for validity (content, construct, face, member checking) and reliability (Cronbach’s alpha, test-retest, intercoder reliability) were implemented to ensure data quality and trustworthiness. Results The mixed-methods approach successfully facilitated the collection of both statistical insights into vaccination rates and an in-depth understanding of underlying beliefs, barriers, and facilitators. The quantitative component provided measurable associations between various factors and HPV uptake while the qualitative component offered rich contextual explanations for these relationships highlighting the "how" and "why" behind observed trends. Conclusion The employed mixed-methods cross-sectional design proved effective in comprehensively investigating the complex factors influencing HPV vaccine uptake in a rural Ugandan setting. This methodological approach allowed for triangulation of data, enhancing the validity and depth of findings. Lessons learned from this design can inform future research aiming to understand multi-faceted public health challenges in similar contexts. Mixed-methods research cross-sectional study HPV vaccination research design methodology data collection qualitative analysis quantitative analysis Uganda public health 1. Introduction/Background Cervical cancer continues to be a major public health concern globally with a disproportionately high burden in low- and middle-income countries.[ 1 ] In Uganda, cervical cancer is the leading cause of cancer related mortality among women with incidence and mortality rates significantly exceeding global averages [ 2 , 3 ]. The Human Papillomavirus (HPV) vaccine offers a critical primary prevention strategy against this disease [ 4 ]. Despite the inclusion of HPV vaccination in Uganda's routine immunization program since 2015, challenges persist, particularly concerning the completion of the two-dose series [ 5 ] National data reveal a consistent drop off between the first and second doses of HPV vaccination series, and in Rukiga District, a dropout rate of 23.49% has been observed [ 3 , 6 , 7 ] Addressing this low uptake of HPV vaccination requires a comprehensive understanding of the multifaceted factors that play spanning individual, health facility and community levels [ 3 , 8 ]. To achieve such a comprehensive understanding the choice of research methodology is paramount. A robust design capable of capturing both statistical associations and rich contextual insights is essential. This paper details the mixed-methods cross-sectional approach adopted to investigate the factors associated with low HPV vaccine uptake in Rukiga District [ 9 ]. It elaborates on the rationale for this design choice, the specific methods employed for data collection and analysis, and the measures taken to ensure the validity and reliability of the findings offering a methodological blueprint for similar public health studies in complex, rural settings. 2. Methods 2.1 Research Approach: This study used a cross-sectional mixed-methods approach, combining quantitative and qualitative data collection [9, 10]. This convergent design allowed for a comprehensive assessment of HPV vaccination uptake. Quantitative methods provided statistical insights into vaccination rates and associated factors, while qualitative methods explored the underlying beliefs, perceptions, barriers, and facilitators, thereby enriching the understanding of the quantitative findings. This methodological triangulation enhanced the validity and depth of the study's conclusions. 2.2 Study Design: A cross-sectional study design was utilized with data collected at a single point in time between September and November 2022. This design was selected for its efficiency in assessing relationships between variables and identifying prevalent trends and barriers within the adolescent girl population of Rukiga District. 2.3 Study Setting: The study was conducted in Rukiga District in southwestern Uganda. The district spans 426.3 km² and has a population of 132,355 people, with a density of 268/km² [11]. Rukiga is primarily rural, with significant portions of its population living more than 5 km from the nearest primary school (about 90%) or health facility (about two-thirds). The district was purposively chosen due to its active HPV vaccination program, its rural setting, documented limited access to health facilities, and its integration into Uganda's Expanded Program for Immunization (UNEPI). Two specific sub-counties with lower vaccination rates and accessibility challenges were selected as study sites [3, 9]. 2.4 Study Population: Quantitative Study: The quantitative study population included parents and guardians of adolescent girls aged 9-14 years who were eligible to receive the HPV vaccine [12,13]. These individuals were chosen because they are primarily responsible for vaccination decisions for their children. Minors (under 18) were excluded as primary respondents to avoid ethical and logistical complexities. Qualitative Study: Key informants for the qualitative component consisted of 11 health workers directly involved in EPI and HPV vaccination activities and 10 Village Health Team (VHT) members [14]. Health workers were chosen for their direct experience in vaccine service delivery, logistics, and school coordination, offering insights into operational strengths and weaknesses. VHTs were included for their role as the immediate link between the health system and the community, providing health education and addressing myths. The inclusion of both groups provided both institutional and population perspectives on factors shaping HPV vaccine uptake. 2.5 Sampling Technique and Sample Size Determination: A multistage sampling approach was employed for the quantitative study. In the first stage, two sub-counties with lower HPV vaccination rates and accessibility challenges were purposively selected. Within these, parishes were selected through simple random sampling, followed by random selection of villages from official lists. Households with eligible adolescent girls (9-14 years) were then selected proportionally to village size, followed by systematic random sampling from a sampling frame of approximately 1,200 households [10,15]. The final quantitative sample size ( n) was calculated using Cochrane’s equation, adjusted for a finite population: n0=Z 2 pq/ e 2 (where Z=1.96 for 95% CI, p=0.5, e=0.05), yielding n0=385. The finite population correction: n=1+N(n0−1)/n0 (where N=1200) resulted in n=291.666667≈292 households. For qualitative data, 11 health workers and 10 VHT members were purposively sampled based on their direct involvement in vaccination activities. 2.6 Inclusion and Exclusion Criteria: Inclusion: Eligible respondents included parents or primary caregivers of adolescent girls aged 9-14 years who were found at home in the selected sub-counties and provided informed consent. Exclusion: Households where caregivers had significant cognitive or hearing impairments were excluded due to challenges in obtaining reliable responses. Additionally, child-headed households were not included, as they may lack sufficient knowledge to provide accurate responses. 2.7 Study Variables: Dependent variable: Low uptake of HPV vaccination series. Independent variables: Factors associated with low HPV vaccine uptake included individual-level barriers (e.g. inadequate knowledge, absenteeism, change of residence, fear of injection, caregiver discouragement, peer discouragement), health facility barriers (e.g. Poor documentation, limited service providers' knowledge, vaccine shortages, understaffing), and community-level barriers (e.g, rumors, religious values, mistrust of government). 2.8 Data Collection Methods: A mixed-methods approach was used, combining semi-structured interviewer-administered questionnaires for quantitative data and Key Informant Interviews (KIIs) for qualitative data. Ten trained research assistants conducted household visits, administering questionnaires. The semi-structured design allowed for both standardized responses and in-depth insights. 2.8.1 Development of Interview Guides: Questionnaires and KII guides were developed by the researcher based on a compilation of published literature on HPV vaccination. Inquiries were organized into broad themes and translated into Rukiga Runyankore with English versions provided as sub-texts. 2.8.2 Pre-testing Tools: Tools were piloted in Kashaki Village, an external site to participating sub-counties. Structured questionnaires were administered among 40 parents/caretakers, and in-depth interviews were done with three health workers and two VHT members. Pre-testing ensured clarity, cultural appropriateness, and allowed for revisions and standardization of the tools prior to main data collection. Interviews were conducted in Rukiga or Runyankole for parents/caretakers, and English for health workers. 2.8.3 Recruitment and Training of Research Assistants: Ten research assistants with proficiency in English and Rukiga-Runyankole, a medical background (nursing or midwifery), and previous interviewing experience were recruited and trained. Training covered interviewing, consent seeking, and maintaining participant confidentiality. Daily supervision was provided to ensure data accuracy and completeness. 2.8.4 Data Collection Tools and Field Editing: Data was collected using pre-tested semi-structured questionnaires and checklists. Field editing was performed daily to ensure accuracy, completeness, and address non-responses. 2.9 Validity and Reliability of the Research Instrument: 2.9.1 Quantitative Data: Validity: Content validity was ensured through expert consultations and literature review. Construct validity was assessed through pilot testing. Face validity was ensured by involving community health workers (VHT members) in reviewing the instrument for clarity, cultural appropriateness, and relevance. Reliability: Confirmed through Cronbach’s alpha (0.72 to 0.83), indicating good internal consistency. Test-retest reliability showed strong stability over time, with a correlation of 0.82 between responses collected two weeks apart [16]. 2.9.2 Qualitative Data: Validity: Member checking was employed by presenting preliminary results to selected participants to confirm the accuracy of interpretations and ensure findings truly reflected their perspectives. Reliability: Intercoder reliability was applied with multiple researchers independently coding a subset of interview transcripts and discrepancies resolved through consensus. 2.10 Data Quality Control: Quality control was ensured through adequate questionnaires, proper identification of key informants, thorough training of research assistants, daily supervision, data review, and systematic data entry. A pre-test of the questionnaire was also conducted. 2.11 Data Management and Analysis: Quantitative Data Analysis: Data were checked for completeness and accuracy, entered into Epi-Info, and then transferred to SPSS for analysis. Univariate analysis generated frequency tables and descriptive parameters. Bivariate analysis compared the dependent variable with independent variables using confidence intervals and p-values. Multivariable logistic regression analysis was conducted to adjust for confounding and determine factors associated with HPV vaccine uptake. All variables from bivariate analysis were included in the multivariable model regardless of whether their p-values fell below the standard threshold of 0.2 to prevent premature removal of potentially significant confounders or clinically/theoretically relevant variables. Qualitative Data Analysis: Open-ended responses were systematically coded by allocating them to frequent themes reflected in the data. This thematic coding allowed for structured interpretation of qualitative input, yielding identifiable trends and patterns between participant responses. This process transformed unstructured personal or descriptive data into structured categories for deeper exploration and effective analysis. 2.12 Ethical Consideration: Ethical approval was obtained from Kabale University and Mbarara University Research Ethics Committee. Permission was also sought from the Rukiga District Health Officer. All potential respondents were informed about the study objectives and procedures, and informed consent was sought prior to interviews. Participation was voluntary, and strict confidentiality was maintained throughout the study. Filled forms were collected daily and kept at the researcher's home to ensure confidentiality. 3. Results The overall completion rate for the two-dose HPV vaccination series in Rukiga District was 27.49%. The study's mixed-methods approach successfully provided both quantitative data on vaccination rates and factors associated with them, as well as qualitative insights into the underlying reasons and contextual influences. The quantitative results derived from the analysis of 292 caregiver questionnaires, identified specific demographic (e.g., caregiver relationship, education, occupation, daughter's class grade) and individual factors (e.g., change of residence, school absenteeism) significantly associated with HPV vaccine uptake. Similarly, health facility factors (e.g., vaccine shortages, understaffing, health worker knowledge) and community factors (e.g., rumors, mistrust of government, religious/cultural opposition) were quantitatively linked to uptake as were knowledge-related factors (e.g., awareness of HPV, eligible age, correct dosage). The qualitative component based on 21 key informant interviews with health workers and VHTs, provided rich thematic data that contextualized and explained the quantitative findings. These themes elaborated on the why behind the observed associations for instance, detailing specific rumors, reasons for school absenteeism, logistical challenges at health facilities, and the impact of health worker knowledge gaps. This triangulation of data sources offered a holistic understanding of the complex interplay of factors influencing HPV vaccine uptake in the study area. Table 1 Showing multivariable logistic regression analysis of factors associated with low uptake of the HPV vaccine series Factor Category Variable Variable Option n OR (95% CI) P-value Demographic Factors Age of Caretaker 20–30 35 0.65 (0.32–1.31) 0.220 31–40 107 0.94 (0.56–1.58) 0.820 41–50 125 1.42 (0.85–2.36) 0.180 50+ (Ref) 12 1.00 – Gender of Caretaker Female 149 2.18 (0.85–5.57) 0.096 Male (Ref) 7 1.00 – Caretaker Relationship Mother 128 1.70 (1.05–2.75) 0.030 Others (Ref) 28 1.00 – Education Level None 2 0.19 (0.04–0.87) 0.033 Primary 96 0.50 (0.30–0.83) 0.007 Secondary+ (Ref) 61 1.00 – Occupation Peasant 111 0.49 (0.28–0.87) 0.013 Employed/Business (Ref) 31 1.00 – Marital Status Married 134 1.43 (0.73–2.80) 0.280 Not Married (Ref) 22 1.00 – Distance to Health Center Distance to Health Center < 1 km 1 Not estimable – 1–3 km (Ref) 110 1.00 – 4–6 km 31 0.96 (0.53–1.74) 0.892 ≥ 6 km 13 1.03 (0.43–2.44) 0.947 Not aware 1 0.87 (0.05–15.4) 0.921 Class Level P2 3 0.89 0.17–4.54 0.87 P3 61 0.95 0.51–1.78 0.83 P4 (Reference) 107 1.00 (Ref) – 1.00 P5 62 0.93 0.49–1.75 0.78 P6 34 1.05 0.49–2.25 0.87 P7 25 1.12 0.48–2.61 0.74 Individual Factors Inadequate knowledge about HPV Yes 207 1.28 (0.89–1.84) 0.114 No 85 0.64 – Change of residence Yes 110 0.50 (0.37–0.69) 0.001 No 182 2.14 – Absenteeism / dropout Yes 175 0.73 (0.59–0.91) 0.037 No 117 2.27 – Caregiver discouragement Yes 182 0.85 (0.69–1.05) 0.222 No 110 1.69 – Poor road infrastructure Yes 209 1.39 (0.92–2.10) 0.108 No 83 0.72 – Fear of injection Yes 201 1.21 (0.83–1.77) 0.311 No 91 0.82 – Peer/Caregiver discouragement Yes 197 1.17 (0.79–1.72) 0.420 No 95 0.85 – Health System Factors Poor records management Yes 194 0.95 (0.72–1.26) 0.109 No 98 1.11 – Limited knowledge by health workers Yes 191 0.94 (0.70–1.24) 0.043 No 101 1.15 – No gov’t program for out of school girls Yes 198 0.97 (0.73–1.29) 0.035 No 94 1.06 – Shortage/cold chain issues Yes 193 1.75 (1.04–2.93) 0.004 No 99 0.52 – Untimely transport Yes 214 0.93 (0.74–1.17) 0.574 No 78 1.25 – Low staff motivation Yes 125 1.06 (0.80–1.41) 0.645 No 77 0.86 – Understaffing Yes 168 1.97 (1.05–3.68) 0.006 No 124 0.58 – Community Factors Rumors / misconceptions Yes 198 1.45 0.033 No 94 0.58 – Religious/cultural opposition Yes 176 1.59 0.031 No 116 0.62 – Mistrust of government Yes 176 1.80 0.009 No 116 0.58 – Busy stakeholder schedules Yes 177 1.29 0.190 No 115 0.73 – Long waiting time Yes 185 0.75 0.046 No 107 2.20 – Knowledge Factors Heard about HPV Yes 269 4.65 (1.89–11.45) 0.001 No 23 1.00 – Knowledge of eligible age Correct (9–14 yrs) 170 2.29 (1.47–3.56) < 0.001 Belief that vaccination is right Yes 262 3.57 (1.52–8.41) 0.003 Knowledge of correct doses Correct (2 doses) 74 2.20 (1.25–3.88) 0.005 Number of doses received One dose 149 1.20 (0.80–1.80) 0.370 Two doses (Ref) 98 1.00 – Don’t know 45 0.62 (0.35–1.12) 0.110 Source : Primary data, 2022 Note : Values that are significant are those with p values < 0.05 (p < 0.05). Since the sample size was limited, not estimable values from bivariate tables (such as those for distances less than one kilometer) were eliminated. Interpretation The results of a multivariate logistic regression analysis evaluating the variables linked to teenage girls' HPV vaccine uptake are shown in Table 1 above. This model covered demographic, individual, health system, community, and knowledge-related domains and included both significant and non-significant factors found during bivariate analysis. Demographic Factors Across all age groups, the caretaker's age did not significantly affect HPV vaccine uptake; AORs of 0.65 (20–30 years), 0.94 (31–40 years), and 1.42 (41–50 years) all had p-values better than 0.05. The caretaker's gender also did not significantly affect uptake; female caregivers had an AOR of 2.18 (p = 0.096) greater than males, suggesting a non-significant tendency toward higher uptake when females are caretakers. When compared to other partnerships, caregivers who were mothers had a significantly higher likelihood of having their daughters vaccinated (AOR of 1.70, 95% CI: 1.05–2.75, p = 0.030), indicating that maternal engagement increases vaccine uptake. Lower education is linked to lower vaccination rates, as evidenced by the significantly lower odds of low vaccine uptake for caregivers with no education (AOR = 0.19, p = 0.033) and primary education (AOR = 0.50, p = 0.007) when compared to those with secondary education or higher. Additionally, occupation was significant: compared to employed or business caregivers, caretakers who were peasants had a considerably lower odds of low vaccine uptake, with an AOR of 0.49 (p = 0.013). Different access or prioritizing patterns may be reflected in this. There was no significant correlation found between vaccination status and other characteristics like marital status or the distance to the health centre. Individual Factors Moving disrupts continuity of treatment among individual factors, a change of residence significantly decreased the likelihood of vaccine uptake with an AOR of 0.50 (95% CI: 0.37–0.69, p = 0.001). The significance of regular school attendance for immunization was further highlighted by the considerable reduction in uptake odds (AOR = 0.73, p = 0.037) caused by absence or school dropout. There was no statistically significant correlation found between any of the other individual components, such as fear of injection, poor road infrastructure, caregiver discouragement, and insufficient HPV knowledge (AOR = 1.28, p = 0.114). Health System Factors Several health system challenges significantly impacted vaccine uptake. Limited knowledge was a substantial obstacle among health personnel (AOR = 0.94, p = 0.043), emphasizing the need for improved training. Another significant obstacle was the lack of a government program for out-of-school girls (AOR = 0.97, p = 0.035), which may indicate outreach limitations. Low uptake odds were raised by logistical concerns such vaccine shortages and cold chain issues (AOR = 1.75, p = 0.004), while understaffing was a significant contributing factor (AOR = 1.97, p = 0.006), indicating human resource limitations that restrict vaccination distribution. This investigation did not find statistical significance for other health system characteristics, such as inadequate records administration, delayed transportation, and low staff enthusiasm. Community Factors Rumors and misconceptions were among the community-related barriers that significantly decreased vaccine uptake by raising reluctance (AOR = 1.45, p = 0.033). Another significant obstacle was religious and cultural resistance (AOR = 1.59, p = 0.031), highlighting the impact of regional beliefs. Furthermore, there was a significant correlation between poorer uptake and mistrust of the government (AOR = 1.80, p = 0.009), suggesting that immunization programs need to foster confidence. Long waiting times significantly decreased uptake (AOR = 0.75, p = 0.046), suggesting that service inefficiencies can discourage caregivers, even while hectic stakeholder schedules were not significant. Knowledge Factors Attitudes and knowledge were found to be effective facilitators. The influence of awareness was demonstrated by the fact that caregivers who had heard about HPV were more than four times as likely to vaccinate their daughters (AOR = 4.65, p = 0.001). Vaccination probabilities were twice when the right eligible age (9–14 years) was known (AOR = 2.29, p < 0.001). Similarly, uptake was significantly higher when people thought that getting vaccinated was the appropriate choice (AOR = 3.57, p = 0.003). Completing the vaccination was also significantly aided by knowing the proper dosage schedule, which calls for two doses (AOR = 2.20, p = 0.005). There was no significant correlation between uptake status and the number of doses received (one versus two). Summary The main obstacles and enablers of HPV vaccine adoption are identified by this logistic regression analysis. Mothers and more educated caretakers exhibit higher vaccination uptake, which is influenced by demographic factors such as caretaker relationship and educational attainment. The possibility of immunization is greatly decreased by individual factors like absenteeism and shifting domicile. Major difficulties in the health system include understaffing, vaccine shortages, lack of outreach for out-of-school girls, and poor health professional education. Rumors, cultural resistance, and mistrust are examples of community characteristics that further hinder uptake. On the other hand, vaccine coverage is significantly increased by good attitudes and understanding regarding HPV and vaccination. Improving the study population's uptake of the HPV vaccine requires addressing these complex concerns. Qualitative data analysis and interpretation from key informant interview (VHTs and Health workers) The main themes, subthemes, and categories derived from key informant interviews with health professionals and Village Health team members (VHTs) about individual, health facility, and community barriers to factors linked to low HPV vaccine serries uptake among adolescents in Rukiga District are shown in Table 2 below. The themes examine community, institutional, and individual factors related to the poor HPV vaccine uptake among adolescent females in Rukiga District. Table 2 Thematic Qualitative data analysis presentation of barriers to HPV vaccination in Rukiga District Theme Subtheme Categories Individual-Level Barriers Lack of Awareness Among Caregivers - Uncertainty about vaccination eligibility (e.g., belief that only girls below 10 qualify). - Limited knowledge about the HPV vaccine. Absenteeism and School Dropout - School absence due to unpaid fees, household responsibilities, or early menstruation. - Some parents keep children home for farm work. Relocation and School Transfers - Families frequently relocate, disrupting vaccine follow-ups. - Parents are often uninformed about vaccination continuity Physical Barriers - Hard-to-reach areas with poor road networks limit vaccine access. Fear of Injection Pain -Aadolescents hesitate to complete the HPV vaccination Negative Influence from Caregivers or Peers -Care givers hold misconceptions. -Peers sharing stories of adverse effects or express skepticism Health facility barriers Limited Knowledge Among Healthcare Workers, VHTs, and Teachers - Unclear understanding of HPV vaccination guidelines. Cold Chain and Logistical Challenges - Shortages of ice packs limit the number of doses transported. - Some facilities lack refrigeration for proper vaccine storage. Inadequate Community Engagement and Mobilization - Shortages of ice packs limit the number of doses transported. - Some facilities lack refrigeration for proper vaccine storage Inadequate Community Engagement and Mobilization - Seasonal activities prevent girls from accessing vaccine information. - Many families remain unaware of vaccination campaigns. Transportation Challenges - Lack of reliable transport disrupts vaccine delivery. - Canceled or delayed vaccination sessions cause frustration. Expectations of Monetary Incentives - Healthcare workers and teachers are demotivated by inadequate allowances Staff Shortages - Limited personnel available for vaccination services. Unfriendly Behavior from Healthcare Workers - Some healthcare workers exhibit rude or discouraging attitudes. Community Level Barriers Rumors and Misconceptions Beliefs that the vaccine promotes early sexual activity. - Concerns about infertility and reproductive health risks. Traditional and Religious Beliefs - Perceptions that vaccination contradicts cultural or religious norms. - Some believe being vaccinated violates traditional rules. Interpretation of Findings from the qualitative data analysis in table above The qualitative findings revealed multiple barriers to HPV vaccine uptake at individual, health system factors and community levels in Rukiga District. Individual Level Barriers A major individual barrier was insufficient caregiver knowledge about HPV vaccination eligibility and benefits. Many caregivers mistakenly thought the vaccine was only for girls under 10 years old, which led to missed vaccinations among older adolescents. As one caregiver explained, “Girls aged 10 and under are vaccinated” (VHT, Health Facility #7). Health workers also noted this lack of understanding: “The HPV vaccine is not well understood by them” (HCW, Health Facility #8). Frequent absenteeism and school dropout due to menstruation, unpaid fees, and household work reduced girls’ attendance during vaccination days. One health worker observed, “Some of the P4 girls have already begun having periods; they don't go to school during that time” (HCW, Health Facility #7), while another added, “Due to problems with school fees, some girls were sent home...” (HCW, Health Facility #5). Additionally, a VHT stated, “When a child has too much work in the garden, parents may decide to keep them from attending school” (VHT, Health Facility #1). Frequent family relocation and school transfers disrupted the vaccination schedule, causing girls to miss second doses. For example, “We had administered the initial dose, but they were not present because of absenteeism and school dropout. Although their parents had moved children to a different school in a different district, we attempted to locate them” (HCW, Health Facility #2). A VHT concurred: “You discover the mother will move with the girls, preventing them from receiving the vaccination” (VHT, Health Facility #6). Physical barriers such as poor roads, especially during rainy seasons, limited access to health facilities. One caregiver described, “The road to the health centre is too bad, especially when it rains. Some people fail to reach there in time” (VHT, Health Facility #5). Fear of injection pain was another deterrent for many girls. A VHT reported, “Some girls are scared because the injection hurts, so they hide or refuse” (VHT, Health Facility #1). Peer influence compounded this fear: “Some girls said this injection is very painful... they refused to go back for the second dose” (VHT, Health Facility #3). Negative peer and parental influence, often based on misconceptions about infertility and side effects, further discouraged vaccine uptake. As a caregiver explained, “Some parents say the vaccine can make a girl barren, so others also start to fear it” (HCW, Health Facility #10). Health Facility Level Barriers At the health facility level, limited knowledge about HPV vaccination guidelines among healthcare workers, VHTs, and teachers hindered effective community mobilization and caregiver education. One health worker stated, “We were not trained well about HPV; we only hear about it when campaigns come” (HCW, Health Facility #9). Logistical challenges including vaccine stock-outs, cold chain deficiencies, and transport difficulties disrupted service delivery. For instance, “When the vaccine is out of stock and you are scheduled to vaccinate these 10-year-old girls...” (HCW, Health Facility #1), and “Some girls were left out because the vaccine got finished” (VHT, Health Facility #3). Cold chain problems were also reported: “Vaccine carrier ice packs are insufficient... the logistics are not enough” (HCW, Health Facility #1). Community sensitization was inadequate, with many caregivers unaware of vaccination schedules. A health worker remarked, “The majority of families were unaware... medical professionals would simply vaccinate these girls without providing an explanation” (HCW, Health Facility #2). Seasonal farming further reduced attendance: “People spend time in gardens during the cultivation season and fail to notice the messages of mobilizers” (HCW, Health Facility #1). Transportation challenges frequently delayed or canceled outreach efforts. A VHT explained, “We occasionally get a bike to vaccinate girls, but it breaks down on the way. Transportation is a problem” (VHT, Health Facility #1). Frustration was expressed by caregivers waiting for postponed vaccinations: “Sometimes they announce vaccination but children wait even for three days in vain” (HCW, Health Facility #3). Staff shortages led to service delays and limited coverage. One health assistant noted, “When we are few, we can't reach all the schools. So some girls miss out” (HCW, Health Facility #6). Lack of incentives also dampened motivation: “We need an allowance for moving... when unmotivated, we sometimes just sit and relax” (VHT, Health Facility #4). Finally, unfriendly behavior from some healthcare workers discouraged vaccine completion. A caregiver shared, “The nurse shouted at me when I asked questions, so I didn’t go back for the second dose” (HCW, Health Facility #4). Community Level Barriers Misinformation and rumors were prevalent in the community, including beliefs that the vaccine causes infertility or promotes early sexual activity. One participant stated, “They say the vaccine will make girls promiscuous or that they will never give birth” (VHT, Health Facility #8). Religious and cultural objections further reduced vaccine acceptance. A religious leader expressed, “Our religion does not support giving children such vaccines. It’s like we are forcing God’s will” (HCW, Health Facility #5). 4. Discussion The employment of a mixed-methods, cross-sectional design was instrumental in providing a comprehensive understanding of the complex factors influencing HPV vaccine uptake in Rukiga District. This methodological choice allowed for the collection of both breadth (through quantitative data on associations) and depth (through qualitative data on underlying perceptions and experiences) enhancing the robustness of the findings. The cross-sectional nature of the study provided an efficient snapshot of the factors at a given time. While this design limits the ability to establish causal relationships, it is highly effective for identifying prevalence rates and existing associations, which is crucial for informing public health program planning. For instance, the study clearly identified the overall low completion rate of 27.49% [ 6] and specific factors statistically associated with it such as caregiver education (AOR = 0.19, p = 0.033) and vaccine shortages (AOR = 1.75, p = 0.004) [ 17 ]. The multi-stage sampling strategy, combined with systematic random sampling for households, aimed to ensure representativeness of the quantitative data within the selected rural sub-counties. However, the study was confined to a single district meaning that while the findings are relevant to similar low-resource rural settings direct generalizability to all of Uganda or other contexts may be limited due to differing sociocultural and infrastructural dynamics. The integration of qualitative data proved invaluable for interpreting the quantitative findings. For example, while the quantitative analysis showed a statistical association between mistrust of government and lower uptake of HPV vaccination in adolescent girls (AOR = 1.80, p = 0.009), the qualitative interviews elaborated on the specific nature of this mistrust, revealing fears of infertility and conspiracy theories, which provided crucial context for designing targeted communication strategies [ 18 ]. Similarly, qualitative insights explained why factors like "fear of injection" or "poor road infrastructure," though not statistically significant in the final quantitative model, remained important lived experiences influencing HPV vaccination decisions [ 19 ]. This highlights the strength of mixed methods in providing nuanced interpretations that quantitative data alone could not. Measures to ensure data quality, including rigorous training of research assistants, daily supervision, pre-testing of tools and employing validity and reliability checks, were critical in enhancing the credibility and trustworthiness of the results. The use of culturally appropriate language (Rukiga Runyankore) in data collection tools further ensured that questions were understood and responses were authentic. One inherent limitation of the study's methodology is its reliance on self-reported data from caregivers and health workers, which is susceptible to recall bias or social desirability bias. Additionally, despite training, potential interviewer bias cannot be entirely ruled out. The exclusion of adolescent girls themselves as primary respondents also means their direct perspectives though partially captured through caregiver reports were not fully explored. Overall, the mixed-methods, cross-sectional design successfully achieved the study's objectives, providing a robust evidence base for understanding HPV vaccine uptake by adolescent girls in rural Uganda. The combination of statistical associations with rich qualitative narratives offers actionable insights for program planners and policymakers. 5. Conclusion The present study successfully utilized a mixed-methods, cross-sectional design to comprehensively investigate the complex factors influencing HPV vaccine uptake among adolescent girls in Rukiga District, Uganda. This methodological approach allowed for the triangulation of quantitative associations and rich qualitative insights, providing a nuanced understanding of demographic, individual, health facility and community level barriers. The rigorous measures for data quality including comprehensive training and validation techniques, underpinned the trustworthiness of the findings. The insights gained demonstrate the critical value of employing mixed-methods designs in complex public health research, particularly in low-resource settings, where context-specific understanding is paramount for developing effective and equitable interventions. 6. Recommendations 6.1 Recommendations for Methodological Improvements in Future Research: Future research on HPV vaccination should adopt longitudinal designs to track changes over time and better establish causal relationships. Including the voices of adolescent girls aged 9–14, through ethical and age-appropriate methods, would provide richer insight into personal barriers and motivations. Expanding the pool of key informants to include district policymakers, program managers, and education representatives, alongside health workers and VHTs, would ensure a broader health system perspective. Direct observation of vaccination sessions and cold chain management could validate self-reported data and uncover operational challenges. Building on these insights, pilot interventions such as enhanced community sensitization or flexible vaccination schedules should be implemented and rigorously evaluated using implementation science approaches to determine their effectiveness 7. Study Limitations The study’s cross-sectional design limits causal interpretation of observed associations. Reliance on self-reported data from caregivers and health workers introduces potential recall and social desirability bias, especially on sensitive topics like religion and vaccine hesitancy. Findings are context-specific to Rukiga District and may not be fully generalizable to other regions in Uganda due to differing sociocultural and infrastructural factors. Despite training, interviewer bias remains a possibility in face-to-face interviews. Additionally, the study primarily reflects caregiver perspectives, omitting insights from adolescents, health facility managers, and district policymakers that could enrich understanding of vaccine uptake barriers. 8. Future Research Directions Future studies should examine how male caregiver involvement varies by residence, education, and HPV information exposure, using mixed methods to identify ways to enhance their engagement. Implementation science approaches could compare the effectiveness and cost efficiency of school- versus clinic-based vaccine delivery with or without SMS reminders through cluster randomized trials. Research should also investigate how misinformation spreads in rural areas and identify trusted correction channels to inform tailored communication strategies. Finally, participatory action research with religious leaders could explore framing HPV vaccination within religious values to foster greater community acceptance and advocacy. 9. Cultural and Contextual Considerations: This study deepens the understanding of how Uganda’s cultural and religious environment shapes HPV vaccine uptake. The qualitative insights, in particular, provided crucial context for understanding how factors like community mistrust and religious beliefs shape perceptions and behaviors. This highlights the importance of incorporating local cultural and social dynamics into research designs and intervention development in similar settings. The finding that religious engagement enhances vaccination (AOR = 0.62) may reflect the trusted role of churches and mosques in health communication and alignment between cancer prevention and religious values of protecting life. This contrasts with some Western contexts, where religious narratives have occasionally impeded vaccine uptake. Future interventions should therefore be locally tailored, building partnerships with faith-based organizations to foster vaccine acceptance. 10. Application and Policy Connections: The robust methodology and findings from this study directly inform Uganda's 2025 Health Sector Development Plan (HSDP) goal of increasing adolescent immunization coverage. The detailed understanding of barriers across individual, health facility, and community levels provides a strong evidence base for targeted policy revisions and program adaptations, particularly concerning: strengthening cooperation between the education sector for school-based delivery; assisting VHTs with tracking and awareness initiatives for community outreach; and resolving obstacles for nomadic and out-of-school populations to ensure fair access. The methodological lessons learned can also serve as a blueprint for evaluating future public health interventions in the country. Example of an Implementation Framework: Making the Switch to Age-Based Vaccination : This study's methodology could be applied to inform administrative changes by updating Ministry of Health and Education joint protocols and school records with birth dates to track eligibility. Capacity building for medical staff would involve teaching them how to verify age, and educating educators on new standards and referral channels. Monitoring coverage by age groups (lasting one year) and comparing uptake between girls who attend school and those who do not is essential. Launching trial projects in two to three districts could utilize aspects of this mixed-methods approach to assess reach, adoption, and sustainability using the RE-AIM paradigm, prior to nationwide implementation. Declarations Ethics Approval and Consent to Participate: This study was conducted in accordance with the Declaration of Uganda National Council for Science and Technology and all applicable ethical guidelines for research involving human participants. Clearance to conduct this study was obtained from the Department of community at Kable, under registration number 2018/MPH/1659/W. Further ethical approval was granted by office of District Health officer Rukiga District and final clearance for data collection was obtained from the Uganda National Council for Science and Technology (UNCST), reference number MUST-2022-511. Informed consent was obtained from all participants prior to their involvement in the study. Consent for Publication: The researchers obtained written consent to use quotes from participants in publications. Data Availability: The primary study document, including the detailed information and dataset used and analyzed and is available upon reasonable request from the corresponding author. Competing Interests: The authors hereby declare that they have no competing interests. Funding: No external funding was received for this work Authors’ Contributions : Mbonigaba Rukarama Evarist conceptualized the study, designed the study framework, led data collection and interpretation, prepared the manuscript, and reviewed the paper. He is the principal investigator. Ronald Arineitwe Kibonire, as co-author, provided guidance throughout the study's conception, design, data collection and analysis phases, reviewed the manuscript, and offered valuable feedback for refinement. He served as the co-investigator. Acknowledgements: We express our gratitude to the community of Rubanda for their participation in this study. Our sincere thanks go to the Office of the District Health Officer of Rukiga District for granting us permission to conduct the research in the district. We also extend special appreciation to the health facility staff of the selected facilities of Rukiga District and VHT members for their support in coordinating and mobilizing respondents for the study and even also giving their views as participants. References Duncan, J., Harris, M., Skyers, N., Bailey, A., & Figueroa, J. P. (2021). A call for low-and middle-income countries to commit to the elimination of cervical cancer. The Lancet Regional Health–Americas , 2 . Anumolu, N., Lechleitner, K., Patel, N., Mijumbi, A., Jankowski, C., Anguzu, R., ... & Beyer, K. (2022). “By the time they run into the hospital, their life is already at stake”: a qualitative study of healthcare professional perceptions on priorities for cervical cancer policy in Uganda. Journal of Global Health Reports , 6 , e2022030. Kajabwangu, R., Bajunirwe, F., Izudi, J., Bazira, J., Farjardo, Y., Ssedyabane, F., ... & Ngonzi, J. (2024). Magnitude and trends in cervical cancer at Mbarara Regional Referral Hospital in South Western Uganda: Retrospective analysis of data from 2017–2022. PLOS Global Public Health , 4 (1), e0002848. Mulongo, M., & Chibwesha, C. J. (2022). Prevention of cervical cancer in low-resource African settings. Obstetrics and Gynecology Clinics , 49 (4), 771-781. Rujumba, J., Akugizibwe, M., Basta, N. E., & Banura, C. (2021). Why don’t adolescent girls in a rural Uganda district initiate or complete routine 2-dose HPV vaccine series: Perspectives of adolescent girls, their caregivers, healthcare workers, community health workers and teachers. PloS one , 16 (6), e0253735. District Health Information Software 2 (DHIS2). (2024). Rukiga District HPV vaccination data. Ministry of Health, Uganda. 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. Clave Llavall, A., de Wildt, G., Meza, G., Tattsbridge, J., & Jones, L. (2021). Nurses’ and teachers’ perceived barriers and facilitators to the uptake of the Human Papilloma Virus (HPV) vaccination program in Iquitos, Peru: A qualitative study. PloS one , 16 (7), e0255218. Asiimwe, S., Bagenda, F. N., & Mugisa, T. (2025). 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, Western Uganda. PloS one , 20 (3), e0306960. Bitariho, G. K., Tuhebwe, D., Tigaiza, A., Nalugya, A., Ssekamatte, T., & Kiwanuka, S. N. (2023). Knowledge, perceptions and uptake of human papilloma virus vaccine among adolescent girls in Kampala, Uganda; a mixed-methods school-based study. BMC pediatrics , 23 (1), 368. Rukiga NHPC, 2024. https://statistics.ubos.org/nphc/drilldown?subregion Jin, S. W., Lee, Y., & Brandt, H. M. (2023). Human papillomavirus (HPV) vaccination knowledge, beliefs, and hesitancy associated with stages of parental readiness for adolescent HPV vaccination: implications for HPV vaccination promotion. Tropical medicine and infectious disease , 8 (5), 251. Wijayanti, K. E., Schütze, H., & MacPhail, C. (2021). Parents’ attitudes, beliefs and uptake of the school-based human papillomavirus (HPV) vaccination program in Jakarta, Indonesia–A quantitative study. Preventive Medicine Reports , 24 , 101651. Elit, L., Ngalla, C., Afugchwi, G. M., Tum, E., Domgue, J. F., & Nouvet, E. (2022). Assessing knowledge, attitudes and belief toward HPV vaccination of parents with children aged 9–14 years in rural communities of Northwest Cameroon: a qualitative study. BMJ open , 12 (11), e068212. Ahmed, D., VanderEnde, K., Harvey, P., Bhatnagar, P., Kaur, N., Roy, S., ... & Loharikar, A. (2022). Human papillomavirus (HPV) vaccine introduction in Sikkim state: Best practices from the first statewide multiple-age cohort HPV vaccine introduction in India–2018–2019. Vaccine , 40 , A17-A25. Jahrami, H., Trabelsi, K., Saif, Z., Manzar, M. D., Bahammam, A. S., & Vitiello, M. V. (2023). Reliability generalization meta-analysis of the Athens Insomnia Scale and its translations: Examining internal consistency and test-retest validity. Sleep Medicine , 111 , 133-145. Karafillakis, E., Peretti-Watel, P., Verger, P., Chantler, T., & Larson, H. J. (2022). ‘I trust them because my mum trusts them’: exploring the role of trust in HPV vaccination decision-making among adolescent girls and their mothers in France. Vaccine , 40 (8), 1090-1097. Beyen, M. W. M., Bulto, G. A., Chaka, E. E., Debelo, B. T., Roga, E. Y., Wakgari, N., ... & Fekene, D. B. (2022). Human papillomavirus vaccination uptake and its associated factors among adolescent school girls in Ambo town, Oromia region, Ethiopia, 2020. PloS one , 17 (7), e0271237. Edwin, R., Mackay, C., & Mda, S. (2022). Missed Opportunities: A Cross-Sectional Descriptive Study on Reasons for Nonadherence to the South African Expanded Program on Immunization. Journal of Pediatric Infectious Diseases , 17 (06), 282-288. 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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-7444969","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":508103560,"identity":"f2b9eca9-0b26-4933-a22b-8a8744a23846","order_by":0,"name":"Mbonigaba Rukarama Evarist","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAyklEQVRIiWNgGAWjYFACHiA2YGDgB7ETCkjRItkA0mJAtBaQrgMMEL0EAb/Y2YOPCwps7I3Pr0788MCAQZ5f7AB+LZKz85KNZxikJW678XazBNBhhjNnJ+DXYnA7x0yax+BwgtmNsxtAWhIMbhPQYg/R8t/eeMbZzT+I0mIgDdZygHEDf+824myRuA30C49BcuKMG7zbLBIMJAj7hX927sHHPH/s7Pn7z26++aPCRp5fmoAWJPvAKiWIVQ627wApqkfBKBgFo2AkAQBAUz/aTNcgHQAAAABJRU5ErkJggg==","orcid":"","institution":"Kabale University","correspondingAuthor":true,"prefix":"","firstName":"Mbonigaba","middleName":"Rukarama","lastName":"Evarist","suffix":""},{"id":508103561,"identity":"0c1f5816-2e1f-4047-a60d-662bfedd9442","order_by":1,"name":"Ronald Arineitwe Kibonire","email":"","orcid":"","institution":"Kabale University","correspondingAuthor":false,"prefix":"","firstName":"Ronald","middleName":"Arineitwe","lastName":"Kibonire","suffix":""}],"badges":[],"createdAt":"2025-08-24 08:38:07","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7444969/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7444969/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":91316917,"identity":"00990a56-c7af-4cc1-9fe0-7f2cded12a2f","added_by":"auto","created_at":"2025-09-15 08:30:00","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1468329,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7444969/v1/30cb176b-9a97-47fb-ad35-8858f7fbb94c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Designing for insight. A Mixed-Methods Approach to Unpacking HPV Vaccine Uptake in Rural Uganda","fulltext":[{"header":"1. Introduction/Background","content":"\u003cp\u003eCervical cancer continues to be a major public health concern globally with a disproportionately high burden in low- and middle-income countries.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] In Uganda, cervical cancer is the leading cause of cancer related mortality among women with incidence and mortality rates significantly exceeding global averages [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The Human Papillomavirus (HPV) vaccine offers a critical primary prevention strategy against this disease [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDespite the inclusion of HPV vaccination in Uganda's routine immunization program since 2015, challenges persist, particularly concerning the completion of the two-dose series [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] National data reveal a consistent drop off between the first and second doses of HPV vaccination series, and in Rukiga District, a dropout rate of 23.49% has been observed [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] Addressing this low uptake of HPV vaccination requires a comprehensive understanding of the multifaceted factors that play spanning individual, health facility and community levels [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eTo achieve such a comprehensive understanding the choice of research methodology is paramount. A robust design capable of capturing both statistical associations and rich contextual insights is essential. This paper details the mixed-methods cross-sectional approach adopted to investigate the factors associated with low HPV vaccine uptake in Rukiga District [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. It elaborates on the rationale for this design choice, the specific methods employed for data collection and analysis, and the measures taken to ensure the validity and reliability of the findings offering a methodological blueprint for similar public health studies in complex, rural settings.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cp\u003e\u003cstrong\u003e2.1 Research Approach:\u003c/strong\u003e This study used a cross-sectional mixed-methods approach, combining quantitative and qualitative data collection [9, 10]. This convergent design allowed for a comprehensive assessment of HPV vaccination uptake. Quantitative methods provided statistical insights into vaccination rates and associated factors, while qualitative methods explored the underlying beliefs, perceptions, barriers, and facilitators, thereby enriching the understanding of the quantitative findings. This methodological triangulation enhanced the validity and depth of the study's conclusions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.2 Study Design:\u003c/strong\u003e A cross-sectional study design was utilized with data collected at a single point in time between September and November 2022. This design was selected for its efficiency in assessing relationships between variables and identifying prevalent trends and barriers within the adolescent girl population of Rukiga District.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.3 Study Setting:\u003c/strong\u003e The study was conducted in Rukiga District in southwestern Uganda. The district spans 426.3 km² and has a population of 132,355 people, with a density of 268/km² [11]. Rukiga is primarily rural, with significant portions of its population living more than 5 km from the nearest primary school (about 90%) or health facility (about two-thirds). The district was purposively chosen due to its active HPV vaccination program, its rural setting, documented limited access to health facilities, and its integration into Uganda's Expanded Program for Immunization (UNEPI). Two specific sub-counties with lower vaccination rates and accessibility challenges were selected as study sites [3, 9].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.4 Study Population:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQuantitative Study:\u003c/strong\u003e The quantitative study population included parents and guardians of adolescent girls aged 9-14 years who were eligible to receive the HPV vaccine [12,13]. These individuals were chosen because they are primarily responsible for vaccination decisions for their children. Minors (under 18) were excluded as primary respondents to avoid ethical and logistical complexities.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQualitative Study:\u003c/strong\u003e Key informants for the qualitative component consisted of 11 health workers directly involved in EPI and HPV vaccination activities and 10 Village Health Team (VHT) members [14]. Health workers were chosen for their direct experience in vaccine service delivery, logistics, and school coordination, offering insights into operational strengths and weaknesses. VHTs were included for their role as the immediate link between the health system and the community, providing health education and addressing myths. The inclusion of both groups provided both institutional and population perspectives on factors shaping HPV vaccine uptake.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.5 Sampling Technique and Sample Size Determination:\u0026nbsp;\u003c/strong\u003eA multistage sampling approach was employed for the quantitative study. In the first stage, two sub-counties with lower HPV vaccination rates and accessibility challenges were purposively selected. Within these, parishes were selected through simple random sampling, followed by random selection of villages from official lists. Households with eligible adolescent girls (9-14 years) were then selected proportionally to village size, followed by systematic random sampling from a sampling frame of approximately 1,200 households [10,15]. The final quantitative sample size (\u003c/p\u003e\n\u003cp\u003en) was calculated using Cochrane’s equation, adjusted for a finite population:\u003c/p\u003e\n\u003cp\u003en0=Z\u003csup\u003e2\u003c/sup\u003epq/ e\u003csup\u003e2\u003c/sup\u003e (where Z=1.96 for 95% CI, p=0.5, e=0.05), yielding n0=385.\u003c/p\u003e\n\u003cp\u003eThe finite population correction:\u003c/p\u003e\n\u003cp\u003en=1+N(n0−1)/n0 (where N=1200) resulted in n=291.666667≈292 households.\u003c/p\u003e\n\u003cp\u003eFor qualitative data, 11 health workers and 10 VHT members were purposively sampled based on their direct involvement in vaccination activities.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.6 Inclusion and Exclusion Criteria:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInclusion:\u003c/strong\u003e Eligible respondents included parents or primary caregivers of adolescent girls aged 9-14 years who were found at home in the selected sub-counties and provided informed consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eExclusion:\u003c/strong\u003e Households where caregivers had significant cognitive or hearing impairments were excluded due to challenges in obtaining reliable responses. Additionally, child-headed households were not included, as they may lack sufficient knowledge to provide accurate responses.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.7 Study Variables:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDependent variable:\u003c/strong\u003e Low uptake of HPV vaccination series.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIndependent variables:\u003c/strong\u003e Factors associated with low HPV vaccine uptake included individual-level barriers (e.g. inadequate knowledge, absenteeism, change of residence, fear of injection, caregiver discouragement, peer discouragement), health facility barriers (e.g. Poor documentation, limited service providers' knowledge, vaccine shortages, understaffing), and community-level barriers (e.g, rumors, religious values, mistrust of government).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.8 Data Collection Methods:\u0026nbsp;\u003c/strong\u003eA mixed-methods approach was used, combining semi-structured interviewer-administered questionnaires for quantitative data and Key Informant Interviews (KIIs) for qualitative data. Ten trained research assistants conducted household visits, administering questionnaires. The semi-structured design allowed for both standardized responses and in-depth insights.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.8.1 Development of Interview Guides:\u003c/strong\u003e Questionnaires and KII guides were developed by the researcher based on a compilation of published literature on HPV vaccination. Inquiries were organized into broad themes and translated into Rukiga Runyankore with English versions provided as sub-texts.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.8.2 Pre-testing Tools:\u003c/strong\u003e Tools were piloted in Kashaki Village, an external site to participating sub-counties. Structured questionnaires were administered among 40 parents/caretakers, and in-depth interviews were done with three health workers and two VHT members. Pre-testing ensured clarity, cultural appropriateness, and allowed for revisions and standardization of the tools prior to main data collection. Interviews were conducted in Rukiga or Runyankole for parents/caretakers, and English for health workers.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.8.3 Recruitment and Training of Research Assistants:\u003c/strong\u003e Ten research assistants with proficiency in English and Rukiga-Runyankole, a medical background (nursing or midwifery), and previous interviewing experience were recruited and trained. Training covered interviewing, consent seeking, and maintaining participant confidentiality. Daily supervision was provided to ensure data accuracy and completeness.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.8.4 Data Collection Tools and Field Editing:\u003c/strong\u003e Data was collected using pre-tested semi-structured questionnaires and checklists. Field editing was performed daily to ensure accuracy, completeness, and address non-responses.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.9 Validity and Reliability of the Research Instrument:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.9.1 Quantitative Data:\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eValidity:\u003c/strong\u003e Content validity was ensured through expert consultations and literature review. Construct validity was assessed through pilot testing. Face validity was ensured by involving community health workers (VHT members) in reviewing the instrument for clarity, cultural appropriateness, and relevance.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eReliability:\u003c/strong\u003e Confirmed through Cronbach’s alpha (0.72 to 0.83), indicating good internal consistency. Test-retest reliability showed strong stability over time, with a correlation of 0.82 between responses collected two weeks apart [16].\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003e2.9.2 Qualitative Data:\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eValidity:\u003c/strong\u003e Member checking was employed by presenting preliminary results to selected participants to confirm the accuracy of interpretations and ensure findings truly reflected their perspectives.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eReliability:\u003c/strong\u003e Intercoder reliability was applied with multiple researchers independently coding a subset of interview transcripts and discrepancies resolved through consensus.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003e2.10 Data Quality Control:\u003c/strong\u003e Quality control was ensured through adequate questionnaires, proper identification of key informants, thorough training of research assistants, daily supervision, data review, and systematic data entry. A pre-test of the questionnaire was also conducted.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.11 Data Management and Analysis:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQuantitative Data Analysis:\u003c/strong\u003e Data were checked for completeness and accuracy, entered into Epi-Info, and then transferred to SPSS for analysis. Univariate analysis generated frequency tables and descriptive parameters. Bivariate analysis compared the dependent variable with independent variables using confidence intervals and p-values. Multivariable logistic regression analysis was conducted to adjust for confounding and determine factors associated with HPV vaccine uptake. All variables from bivariate analysis were included in the multivariable model regardless of whether their p-values fell below the standard threshold of 0.2 to prevent premature removal of potentially significant confounders or clinically/theoretically relevant variables.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQualitative Data Analysis:\u003c/strong\u003e Open-ended responses were systematically coded by allocating them to frequent themes reflected in the data. This thematic coding allowed for structured interpretation of qualitative input, yielding identifiable trends and patterns between participant responses. This process transformed unstructured personal or descriptive data into structured categories for deeper exploration and effective analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.12 Ethical Consideration:\u003c/strong\u003e Ethical approval was obtained from Kabale University and Mbarara University Research Ethics Committee. Permission was also sought from the Rukiga District Health Officer. All potential respondents were informed about the study objectives and procedures, and informed consent was sought prior to interviews. Participation was voluntary, and strict confidentiality was maintained throughout the study. Filled forms were collected daily and kept at the researcher's home to ensure confidentiality.\u003c/p\u003e"},{"header":"3. Results","content":"\u003cp\u003eThe overall completion rate for the two-dose HPV vaccination series in Rukiga District was 27.49%. The study's mixed-methods approach successfully provided both quantitative data on vaccination rates and factors associated with them, as well as qualitative insights into the underlying reasons and contextual influences.\u003c/p\u003e\u003cp\u003eThe quantitative results derived from the analysis of 292 caregiver questionnaires, identified specific demographic (e.g., caregiver relationship, education, occupation, daughter's class grade) and individual factors (e.g., change of residence, school absenteeism) significantly associated with HPV vaccine uptake. Similarly, health facility factors (e.g., vaccine shortages, understaffing, health worker knowledge) and community factors (e.g., rumors, mistrust of government, religious/cultural opposition) were quantitatively linked to uptake as were knowledge-related factors (e.g., awareness of HPV, eligible age, correct dosage).\u003c/p\u003e\u003cp\u003eThe qualitative component based on 21 key informant interviews with health workers and VHTs, provided rich thematic data that contextualized and explained the quantitative findings. These themes elaborated on the why behind the observed associations for instance, detailing specific rumors, reasons for school absenteeism, logistical challenges at health facilities, and the impact of health worker knowledge gaps. This triangulation of data sources offered a holistic understanding of the complex interplay of factors influencing HPV vaccine uptake in the study area.\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\u003eShowing multivariable logistic regression analysis of factors associated with low uptake of the HPV vaccine series\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\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\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFactor Category\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eVariable Option\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003en\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eOR (95% CI)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\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\u003eDemographic Factors\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAge of Caretaker\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20\u0026ndash;30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.65 (0.32\u0026ndash;1.31)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.220\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e31\u0026ndash;40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e107\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.94 (0.56\u0026ndash;1.58)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.820\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e41\u0026ndash;50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e125\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.42 (0.85\u0026ndash;2.36)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.180\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e50+ (Ref)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGender of Caretaker\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e149\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.18 (0.85\u0026ndash;5.57)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.096\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale (Ref)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCaretaker Relationship\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMother\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e128\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.70 (1.05\u0026ndash;2.75)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.030\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eOthers (Ref)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEducation Level\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.19 (0.04\u0026ndash;0.87)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.033\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePrimary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e96\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.50 (0.30\u0026ndash;0.83)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.007\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSecondary+ (Ref)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOccupation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePeasant\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e111\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.49 (0.28\u0026ndash;0.87)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.013\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eEmployed/Business (Ref)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMarital Status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e134\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.43 (0.73\u0026ndash;2.80)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.280\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNot Married (Ref)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDistance to Health Center\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDistance to Health Center\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;1 km\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eNot estimable\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1\u0026ndash;3 km (Ref)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e110\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4\u0026ndash;6 km\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.96 (0.53\u0026ndash;1.74)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.892\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;6 km\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.03 (0.43\u0026ndash;2.44)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.947\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNot aware\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.87 (0.05\u0026ndash;15.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.921\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eClass Level\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eP2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.89\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.17\u0026ndash;4.54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.87\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eP3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.95\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.51\u0026ndash;1.78\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.83\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eP4 (Reference)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e107\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.00 (Ref)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1.00\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eP5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e62\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.49\u0026ndash;1.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.78\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eP6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.49\u0026ndash;2.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.87\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eP7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.48\u0026ndash;2.61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.74\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIndividual Factors\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eInadequate knowledge about HPV\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e207\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.28 (0.89\u0026ndash;1.84)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.114\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e85\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eChange of residence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e110\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.50 (0.37\u0026ndash;0.69)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e182\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAbsenteeism / dropout\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e175\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.73 (0.59\u0026ndash;0.91)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.037\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e117\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCaregiver discouragement\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e182\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.85 (0.69\u0026ndash;1.05)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.222\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e110\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePoor road infrastructure\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e209\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.39 (0.92\u0026ndash;2.10)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.108\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e83\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.72\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFear of injection\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e201\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.21 (0.83\u0026ndash;1.77)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.311\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e91\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePeer/Caregiver discouragement\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e197\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.17 (0.79\u0026ndash;1.72)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.420\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e95\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.85\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHealth System Factors\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePoor records management\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e194\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.95 (0.72\u0026ndash;1.26)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.109\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e98\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLimited knowledge by health workers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e191\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.94 (0.70\u0026ndash;1.24)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.043\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e101\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo gov\u0026rsquo;t program for out of school girls\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e198\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.97 (0.73\u0026ndash;1.29)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.035\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e94\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.06\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eShortage/cold chain issues\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e193\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.75 (1.04\u0026ndash;2.93)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.004\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e99\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUntimely transport\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e214\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.93 (0.74\u0026ndash;1.17)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.574\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e78\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLow staff motivation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e125\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.06 (0.80\u0026ndash;1.41)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.645\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e77\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.86\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUnderstaffing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e168\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.97 (1.05\u0026ndash;3.68)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.006\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e124\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCommunity Factors\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRumors / misconceptions\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e198\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.033\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e94\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eReligious/cultural opposition\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e176\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.031\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e116\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.62\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMistrust of government\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e176\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.009\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e116\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBusy stakeholder schedules\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e177\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.190\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e115\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.73\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLong waiting time\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e185\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.046\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e107\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eKnowledge Factors\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHeard about HPV\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e269\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4.65 (1.89\u0026ndash;11.45)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eKnowledge of eligible age\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCorrect (9\u0026ndash;14 yrs)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e170\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.29 (1.47\u0026ndash;3.56)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBelief that vaccination is right\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e262\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3.57 (1.52\u0026ndash;8.41)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.003\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eKnowledge of correct doses\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCorrect (2 doses)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e74\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.20 (1.25\u0026ndash;3.88)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.005\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNumber of doses received\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eOne dose\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e149\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.20 (0.80\u0026ndash;1.80)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.370\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTwo doses (Ref)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e98\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDon\u0026rsquo;t know\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.62 (0.35\u0026ndash;1.12)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.110\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003cb\u003eSource\u003c/b\u003e: Primary data, 2022\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003cb\u003eNote\u003c/b\u003e:\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eValues that are significant are those with p values\u0026thinsp;\u0026lt;\u0026thinsp;0.05 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eSince the sample size was limited, not estimable values from bivariate tables (such as those for distances less than one kilometer) were eliminated.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eInterpretation\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe results of a multivariate logistic regression analysis evaluating the variables linked to teenage girls' HPV vaccine uptake are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e above. This model covered demographic, individual, health system, community, and knowledge-related domains and included both significant and non-significant factors found during bivariate analysis.\u003c/p\u003e\u003cp\u003e\u003cb\u003eDemographic Factors\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAcross all age groups, the caretaker's age did not significantly affect HPV vaccine uptake; AORs of 0.65 (20\u0026ndash;30 years), 0.94 (31\u0026ndash;40 years), and 1.42 (41\u0026ndash;50 years) all had p-values better than 0.05. The caretaker's gender also did not significantly affect uptake; female caregivers had an AOR of 2.18 (p\u0026thinsp;=\u0026thinsp;0.096) greater than males, suggesting a non-significant tendency toward higher uptake when females are caretakers.\u003c/p\u003e\u003cp\u003eWhen compared to other partnerships, caregivers who were mothers had a significantly higher likelihood of having their daughters vaccinated (AOR of 1.70, 95% CI: 1.05\u0026ndash;2.75, p\u0026thinsp;=\u0026thinsp;0.030), indicating that maternal engagement increases vaccine uptake. Lower education is linked to lower vaccination rates, as evidenced by the significantly lower odds of low vaccine uptake for caregivers with no education (AOR\u0026thinsp;=\u0026thinsp;0.19, p\u0026thinsp;=\u0026thinsp;0.033) and primary education (AOR\u0026thinsp;=\u0026thinsp;0.50, p\u0026thinsp;=\u0026thinsp;0.007) when compared to those with secondary education or higher.\u003c/p\u003e\u003cp\u003eAdditionally, occupation was significant: compared to employed or business caregivers, caretakers who were peasants had a considerably lower odds of low vaccine uptake, with an AOR of 0.49 (p\u0026thinsp;=\u0026thinsp;0.013). Different access or prioritizing patterns may be reflected in this. There was no significant correlation found between vaccination status and other characteristics like marital status or the distance to the health centre.\u003c/p\u003e\u003cp\u003e\u003cb\u003eIndividual Factors\u003c/b\u003e\u003c/p\u003e\u003cp\u003eMoving disrupts continuity of treatment among individual factors, a change of residence significantly decreased the likelihood of vaccine uptake with an AOR of 0.50 (95% CI: 0.37\u0026ndash;0.69, p\u0026thinsp;=\u0026thinsp;0.001). The significance of regular school attendance for immunization was further highlighted by the considerable reduction in uptake odds (AOR\u0026thinsp;=\u0026thinsp;0.73, p\u0026thinsp;=\u0026thinsp;0.037) caused by absence or school dropout. There was no statistically significant correlation found between any of the other individual components, such as fear of injection, poor road infrastructure, caregiver discouragement, and insufficient HPV knowledge (AOR\u0026thinsp;=\u0026thinsp;1.28, p\u0026thinsp;=\u0026thinsp;0.114).\u003c/p\u003e\u003cp\u003e\u003cb\u003eHealth System Factors\u003c/b\u003e\u003c/p\u003e\u003cp\u003eSeveral health system challenges significantly impacted vaccine uptake. \u003cb\u003eLimited knowledge\u003c/b\u003e was a substantial obstacle among health personnel (AOR\u0026thinsp;=\u0026thinsp;0.94, p\u0026thinsp;=\u0026thinsp;0.043), emphasizing the need for improved training. Another significant obstacle was the lack of a government program for out-of-school girls (AOR\u0026thinsp;=\u0026thinsp;0.97, p\u0026thinsp;=\u0026thinsp;0.035), which may indicate outreach limitations. Low uptake odds were raised by logistical concerns such vaccine shortages and cold chain issues (AOR\u0026thinsp;=\u0026thinsp;1.75, p\u0026thinsp;=\u0026thinsp;0.004), while understaffing was a significant contributing factor (AOR\u0026thinsp;=\u0026thinsp;1.97, p\u0026thinsp;=\u0026thinsp;0.006), indicating human resource limitations that restrict vaccination distribution. This investigation did not find statistical significance for other health system characteristics, such as inadequate records administration, delayed transportation, and low staff enthusiasm.\u003c/p\u003e\u003cp\u003e\u003cb\u003eCommunity Factors\u003c/b\u003e\u003c/p\u003e\u003cp\u003eRumors and misconceptions were among the community-related barriers that significantly decreased vaccine uptake by raising reluctance (AOR\u0026thinsp;=\u0026thinsp;1.45, p\u0026thinsp;=\u0026thinsp;0.033). Another significant obstacle was religious and cultural resistance (AOR\u0026thinsp;=\u0026thinsp;1.59, p\u0026thinsp;=\u0026thinsp;0.031), highlighting the impact of regional beliefs. Furthermore, there was a significant correlation between poorer uptake and mistrust of the government (AOR\u0026thinsp;=\u0026thinsp;1.80, p\u0026thinsp;=\u0026thinsp;0.009), suggesting that immunization programs need to foster confidence. Long waiting times significantly decreased uptake (AOR\u0026thinsp;=\u0026thinsp;0.75, p\u0026thinsp;=\u0026thinsp;0.046), suggesting that service inefficiencies can discourage caregivers, even while hectic stakeholder schedules were not significant.\u003c/p\u003e\u003cp\u003e\u003cb\u003eKnowledge Factors\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAttitudes and knowledge were found to be effective facilitators. The influence of awareness was demonstrated by the fact that caregivers who had heard about HPV were more than four times as likely to vaccinate their daughters (AOR\u0026thinsp;=\u0026thinsp;4.65, p\u0026thinsp;=\u0026thinsp;0.001). Vaccination probabilities were twice when the right eligible age (9\u0026ndash;14 years) was known (AOR\u0026thinsp;=\u0026thinsp;2.29, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Similarly, uptake was significantly higher when people thought that getting vaccinated was the appropriate choice (AOR\u0026thinsp;=\u0026thinsp;3.57, p\u0026thinsp;=\u0026thinsp;0.003). Completing the vaccination was also significantly aided by knowing the proper dosage schedule, which calls for two doses (AOR\u0026thinsp;=\u0026thinsp;2.20, p\u0026thinsp;=\u0026thinsp;0.005). There was no significant correlation between uptake status and the number of doses received (one versus two).\u003c/p\u003e\u003cp\u003e\u003cb\u003eSummary\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe main obstacles and enablers of HPV vaccine adoption are identified by this logistic regression analysis. Mothers and more educated caretakers exhibit higher vaccination uptake, which is influenced by demographic factors such as caretaker relationship and educational attainment. The possibility of immunization is greatly decreased by individual factors like absenteeism and shifting domicile. Major difficulties in the health system include understaffing, vaccine shortages, lack of outreach for out-of-school girls, and poor health professional education. Rumors, cultural resistance, and mistrust are examples of community characteristics that further hinder uptake. On the other hand, vaccine coverage is significantly increased by good attitudes and understanding regarding HPV and vaccination. Improving the study population's uptake of the HPV vaccine requires addressing these complex concerns.\u003c/p\u003e\u003cp\u003e\u003cb\u003eQualitative data analysis and interpretation from key informant interview (VHTs and Health workers)\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe main themes, subthemes, and categories derived from key informant interviews with health professionals and Village Health team members (VHTs) about individual, health facility, and community barriers to factors linked to low HPV vaccine serries uptake among adolescents in Rukiga District are shown in Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e below. The themes examine community, institutional, and individual factors related to the poor HPV vaccine uptake among adolescent females in Rukiga District.\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\u003eThematic Qualitative data analysis presentation of barriers to HPV vaccination in Rukiga District\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\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\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTheme\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSubtheme\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCategories\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIndividual-Level Barriers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLack of Awareness Among Caregivers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e- Uncertainty about vaccination eligibility (e.g., belief that only girls below 10 qualify).\u003c/p\u003e \u003cp\u003e- Limited knowledge about the HPV vaccine.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAbsenteeism and School Dropout\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e- School absence due to unpaid fees, household responsibilities, or early menstruation.\u003c/p\u003e \u003cp\u003e- Some parents keep children home for farm work.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRelocation and School Transfers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e- Families frequently relocate, disrupting vaccine follow-ups.\u003c/p\u003e \u003cp\u003e- Parents are often uninformed about vaccination continuity\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePhysical Barriers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e- Hard-to-reach areas with poor road networks limit vaccine access.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFear of Injection Pain\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-Aadolescents hesitate to complete the HPV vaccination\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNegative Influence from Caregivers or Peers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-Care givers hold misconceptions.\u003c/p\u003e\u003cp\u003e-Peers sharing stories of adverse effects or express skepticism\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"7\" rowspan=\"8\"\u003e\u003cp\u003eHealth facility barriers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLimited Knowledge Among Healthcare Workers, VHTs, and Teachers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e- Unclear understanding of HPV vaccination guidelines.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCold Chain and Logistical Challenges\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e- Shortages of ice packs limit the number of doses transported.\u003c/p\u003e \u003cp\u003e- Some facilities lack refrigeration for proper vaccine storage.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eInadequate Community Engagement and Mobilization\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e- Shortages of ice packs limit the number of doses transported.\u003c/p\u003e \u003cp\u003e- Some facilities lack refrigeration for proper vaccine storage\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eInadequate Community Engagement and Mobilization\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e- Seasonal activities prevent girls from accessing vaccine information.\u003c/p\u003e \u003cp\u003e- Many families remain unaware of vaccination campaigns.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTransportation Challenges\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e- Lack of reliable transport disrupts vaccine delivery.\u003c/p\u003e \u003cp\u003e- Canceled or delayed vaccination sessions cause frustration.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eExpectations of Monetary Incentives\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e- Healthcare workers and teachers are demotivated by inadequate allowances\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStaff Shortages\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e- Limited personnel available for vaccination services.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUnfriendly Behavior from Healthcare Workers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e- Some healthcare workers exhibit rude or discouraging attitudes.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eCommunity Level Barriers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRumors and Misconceptions\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eBeliefs that the vaccine promotes early sexual activity.\u003c/p\u003e\u003cp\u003e- Concerns about infertility and reproductive health risks.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTraditional and Religious Beliefs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e- Perceptions that vaccination contradicts cultural or religious norms.\u003c/p\u003e \u003cp\u003e- Some believe being vaccinated violates traditional rules.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eInterpretation of Findings from the qualitative data analysis in table above\u003c/p\u003e\u003cp\u003eThe qualitative findings revealed multiple barriers to HPV vaccine uptake at individual, health system factors and community levels in Rukiga District.\u003c/p\u003e\u003cp\u003e\u003cb\u003eIndividual Level Barriers\u003c/b\u003e\u003c/p\u003e\u003cp\u003eA major individual barrier was insufficient caregiver knowledge about HPV vaccination eligibility and benefits. Many caregivers mistakenly thought the vaccine was only for girls under 10 years old, which led to missed vaccinations among older adolescents. As one caregiver explained, \u003cem\u003e\u0026ldquo;Girls aged 10 and under are vaccinated\u0026rdquo;\u003c/em\u003e (VHT, Health Facility #7). Health workers also noted this lack of understanding: \u003cem\u003e\u0026ldquo;The HPV vaccine is not well understood by them\u0026rdquo;\u003c/em\u003e (HCW, Health Facility #8).\u003c/p\u003e\u003cp\u003eFrequent absenteeism and school dropout due to menstruation, unpaid fees, and household work reduced girls\u0026rsquo; attendance during vaccination days. One health worker observed, \u003cem\u003e\u0026ldquo;Some of the P4 girls have already begun having periods; they don't go to school during that time\u0026rdquo;\u003c/em\u003e (HCW, Health Facility #7), while another added, \u003cem\u003e\u0026ldquo;Due to problems with school fees, some girls were sent home...\u0026rdquo;\u003c/em\u003e (HCW, Health Facility #5). Additionally, a VHT stated, \u003cem\u003e\u0026ldquo;When a child has too much work in the garden, parents may decide to keep them from attending school\u0026rdquo;\u003c/em\u003e (VHT, Health Facility #1).\u003c/p\u003e\u003cp\u003eFrequent family relocation and school transfers disrupted the vaccination schedule, causing girls to miss second doses. For example, \u003cem\u003e\u0026ldquo;We had administered the initial dose, but they were not present because of absenteeism and school dropout. Although their parents had moved children to a different school in a different district, we attempted to locate them\u0026rdquo;\u003c/em\u003e (HCW, Health Facility #2). A VHT concurred: \u003cem\u003e\u0026ldquo;You discover the mother will move with the girls, preventing them from receiving the vaccination\u0026rdquo;\u003c/em\u003e (VHT, Health Facility #6).\u003c/p\u003e\u003cp\u003ePhysical barriers such as poor roads, especially during rainy seasons, limited access to health facilities. One caregiver described, \u003cem\u003e\u0026ldquo;The road to the health centre is too bad, especially when it rains. Some people fail to reach there in time\u0026rdquo;\u003c/em\u003e (VHT, Health Facility #5).\u003c/p\u003e\u003cp\u003eFear of injection pain was another deterrent for many girls. A VHT reported, \u003cem\u003e\u0026ldquo;Some girls are scared because the injection hurts, so they hide or refuse\u0026rdquo;\u003c/em\u003e (VHT, Health Facility #1). Peer influence compounded this fear: \u003cem\u003e\u0026ldquo;Some girls said this injection is very painful... they refused to go back for the second dose\u0026rdquo;\u003c/em\u003e (VHT, Health Facility #3).\u003c/p\u003e\u003cp\u003eNegative peer and parental influence, often based on misconceptions about infertility and side effects, further discouraged vaccine uptake. As a caregiver explained, \u003cem\u003e\u0026ldquo;Some parents say the vaccine can make a girl barren, so others also start to fear it\u0026rdquo;\u003c/em\u003e (HCW, Health Facility #10).\u003c/p\u003e\u003cp\u003e\u003cb\u003eHealth Facility Level Barriers\u003c/b\u003e\u003c/p\u003e\u003cp\u003e At the health facility level, limited knowledge about HPV vaccination guidelines among healthcare workers, VHTs, and teachers hindered effective community mobilization and caregiver education. One health worker stated, \u003cem\u003e\u0026ldquo;We were not trained well about HPV; we only hear about it when campaigns come\u0026rdquo;\u003c/em\u003e (HCW, Health Facility #9).\u003c/p\u003e\u003cp\u003eLogistical challenges including vaccine stock-outs, cold chain deficiencies, and transport difficulties disrupted service delivery. For instance, \u003cem\u003e\u0026ldquo;When the vaccine is out of stock and you are scheduled to vaccinate these 10-year-old girls...\u0026rdquo;\u003c/em\u003e (HCW, Health Facility #1), and \u003cem\u003e\u0026ldquo;Some girls were left out because the vaccine got finished\u0026rdquo;\u003c/em\u003e (VHT, Health Facility #3). Cold chain problems were also reported: \u003cem\u003e\u0026ldquo;Vaccine carrier ice packs are insufficient... the logistics are not enough\u0026rdquo;\u003c/em\u003e (HCW, Health Facility #1).\u003c/p\u003e\u003cp\u003eCommunity sensitization was inadequate, with many caregivers unaware of vaccination schedules. A health worker remarked, \u003cem\u003e\u0026ldquo;The majority of families were unaware... medical professionals would simply vaccinate these girls without providing an explanation\u0026rdquo;\u003c/em\u003e (HCW, Health Facility #2). Seasonal farming further reduced attendance: \u003cem\u003e\u0026ldquo;People spend time in gardens during the cultivation season and fail to notice the messages of mobilizers\u0026rdquo;\u003c/em\u003e (HCW, Health Facility #1).\u003c/p\u003e\u003cp\u003eTransportation challenges frequently delayed or canceled outreach efforts. A VHT explained, \u003cem\u003e\u0026ldquo;We occasionally get a bike to vaccinate girls, but it breaks down on the way. Transportation is a problem\u0026rdquo;\u003c/em\u003e (VHT, Health Facility #1). Frustration was expressed by caregivers waiting for postponed vaccinations: \u003cem\u003e\u0026ldquo;Sometimes they announce vaccination but children wait even for three days in vain\u0026rdquo;\u003c/em\u003e (HCW, Health Facility #3).\u003c/p\u003e\u003cp\u003eStaff shortages led to service delays and limited coverage. One health assistant noted, \u003cem\u003e\u0026ldquo;When we are few, we can't reach all the schools. So some girls miss out\u0026rdquo;\u003c/em\u003e (HCW, Health Facility #6). Lack of incentives also dampened motivation: \u003cem\u003e\u0026ldquo;We need an allowance for moving... when unmotivated, we sometimes just sit and relax\u0026rdquo;\u003c/em\u003e (VHT, Health Facility #4).\u003c/p\u003e\u003cp\u003eFinally, unfriendly behavior from some healthcare workers discouraged vaccine completion. A caregiver shared, \u003cem\u003e\u0026ldquo;The nurse shouted at me when I asked questions, so I didn\u0026rsquo;t go back for the second dose\u0026rdquo;\u003c/em\u003e (HCW, Health Facility #4).\u003c/p\u003e\u003cp\u003e\u003cb\u003eCommunity Level Barriers\u003c/b\u003e\u003c/p\u003e\u003cp\u003eMisinformation and rumors were prevalent in the community, including beliefs that the vaccine causes infertility or promotes early sexual activity. One participant stated, \u003cem\u003e\u0026ldquo;They say the vaccine will make girls promiscuous or that they will never give birth\u0026rdquo;\u003c/em\u003e (VHT, Health Facility #8).\u003c/p\u003e\u003cp\u003eReligious and cultural objections further reduced vaccine acceptance. A religious leader expressed, \u003cem\u003e\u0026ldquo;Our religion does not support giving children such vaccines. It\u0026rsquo;s like we are forcing God\u0026rsquo;s will\u0026rdquo;\u003c/em\u003e (HCW, Health Facility #5).\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThe employment of a mixed-methods, cross-sectional design was instrumental in providing a comprehensive understanding of the complex factors influencing HPV vaccine uptake in Rukiga District. This methodological choice allowed for the collection of both breadth (through quantitative data on associations) and depth (through qualitative data on underlying perceptions and experiences) enhancing the robustness of the findings.\u003c/p\u003e\u003cp\u003eThe cross-sectional nature of the study provided an efficient snapshot of the factors at a given time. While this design limits the ability to establish causal relationships, it is highly effective for identifying prevalence rates and existing associations, which is crucial for informing public health program planning. For instance, the study clearly identified the overall low completion rate of 27.49% [ 6] and specific factors statistically associated with it such as caregiver education (AOR\u0026thinsp;=\u0026thinsp;0.19, p\u0026thinsp;=\u0026thinsp;0.033) and vaccine shortages (AOR\u0026thinsp;=\u0026thinsp;1.75, p\u0026thinsp;=\u0026thinsp;0.004) [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe multi-stage sampling strategy, combined with systematic random sampling for households, aimed to ensure representativeness of the quantitative data within the selected rural sub-counties. However, the study was confined to a single district meaning that while the findings are relevant to similar low-resource rural settings direct generalizability to all of Uganda or other contexts may be limited due to differing sociocultural and infrastructural dynamics.\u003c/p\u003e\u003cp\u003eThe integration of qualitative data proved invaluable for interpreting the quantitative findings. For example, while the quantitative analysis showed a statistical association between mistrust of government and lower uptake of HPV vaccination in adolescent girls (AOR\u0026thinsp;=\u0026thinsp;1.80, p\u0026thinsp;=\u0026thinsp;0.009), the qualitative interviews elaborated on the specific nature of this mistrust, revealing fears of infertility and conspiracy theories, which provided crucial context for designing targeted communication strategies [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Similarly, qualitative insights explained why factors like \"fear of injection\" or \"poor road infrastructure,\" though not statistically significant in the final quantitative model, remained important lived experiences influencing HPV vaccination decisions [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. This highlights the strength of mixed methods in providing nuanced interpretations that quantitative data alone could not.\u003c/p\u003e\u003cp\u003eMeasures to ensure data quality, including rigorous training of research assistants, daily supervision, pre-testing of tools and employing validity and reliability checks, were critical in enhancing the credibility and trustworthiness of the results. The use of culturally appropriate language (Rukiga Runyankore) in data collection tools further ensured that questions were understood and responses were authentic.\u003c/p\u003e\u003cp\u003eOne inherent limitation of the study's methodology is its reliance on self-reported data from caregivers and health workers, which is susceptible to recall bias or social desirability bias. Additionally, despite training, potential interviewer bias cannot be entirely ruled out. The exclusion of adolescent girls themselves as primary respondents also means their direct perspectives though partially captured through caregiver reports were not fully explored.\u003c/p\u003e\u003cp\u003eOverall, the mixed-methods, cross-sectional design successfully achieved the study's objectives, providing a robust evidence base for understanding HPV vaccine uptake by adolescent girls in rural Uganda. The combination of statistical associations with rich qualitative narratives offers actionable insights for program planners and policymakers.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eThe present study successfully utilized a mixed-methods, cross-sectional design to comprehensively investigate the complex factors influencing HPV vaccine uptake among adolescent girls in Rukiga District, Uganda. This methodological approach allowed for the triangulation of quantitative associations and rich qualitative insights, providing a nuanced understanding of demographic, individual, health facility and community level barriers. The rigorous measures for data quality including comprehensive training and validation techniques, underpinned the trustworthiness of the findings. The insights gained demonstrate the critical value of employing mixed-methods designs in complex public health research, particularly in low-resource settings, where context-specific understanding is paramount for developing effective and equitable interventions.\u003c/p\u003e"},{"header":"6. Recommendations","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003e6.1 Recommendations for Methodological Improvements in Future Research:\u003c/h2\u003e\u003cp\u003eFuture research on HPV vaccination should adopt longitudinal designs to track changes over time and better establish causal relationships. Including the voices of adolescent girls aged 9\u0026ndash;14, through ethical and age-appropriate methods, would provide richer insight into personal barriers and motivations. Expanding the pool of key informants to include district policymakers, program managers, and education representatives, alongside health workers and VHTs, would ensure a broader health system perspective. Direct observation of vaccination sessions and cold chain management could validate self-reported data and uncover operational challenges. Building on these insights, pilot interventions such as enhanced community sensitization or flexible vaccination schedules should be implemented and rigorously evaluated using implementation science approaches to determine their effectiveness\u003c/p\u003e\u003c/div\u003e"},{"header":"7. Study Limitations","content":"\u003cp\u003eThe study\u0026rsquo;s cross-sectional design limits causal interpretation of observed associations. Reliance on self-reported data from caregivers and health workers introduces potential recall and social desirability bias, especially on sensitive topics like religion and vaccine hesitancy. Findings are context-specific to Rukiga District and may not be fully generalizable to other regions in Uganda due to differing sociocultural and infrastructural factors. Despite training, interviewer bias remains a possibility in face-to-face interviews. Additionally, the study primarily reflects caregiver perspectives, omitting insights from adolescents, health facility managers, and district policymakers that could enrich understanding of vaccine uptake barriers.\u003c/p\u003e"},{"header":"8. Future Research Directions","content":"\u003cp\u003eFuture studies should examine how male caregiver involvement varies by residence, education, and HPV information exposure, using mixed methods to identify ways to enhance their engagement. Implementation science approaches could compare the effectiveness and cost efficiency of school- versus clinic-based vaccine delivery with or without SMS reminders through cluster randomized trials. Research should also investigate how misinformation spreads in rural areas and identify trusted correction channels to inform tailored communication strategies. Finally, participatory action research with religious leaders could explore framing HPV vaccination within religious values to foster greater community acceptance and advocacy.\u003c/p\u003e"},{"header":"9. Cultural and Contextual Considerations:","content":"\u003cp\u003eThis study deepens the understanding of how Uganda\u0026rsquo;s cultural and religious environment shapes HPV vaccine uptake. The qualitative insights, in particular, provided crucial context for understanding how factors like community mistrust and religious beliefs shape perceptions and behaviors. This highlights the importance of incorporating local cultural and social dynamics into research designs and intervention development in similar settings. The finding that religious engagement enhances vaccination (AOR\u0026thinsp;=\u0026thinsp;0.62) may reflect the trusted role of churches and mosques in health communication and alignment between cancer prevention and religious values of protecting life. This contrasts with some Western contexts, where religious narratives have occasionally impeded vaccine uptake. Future interventions should therefore be locally tailored, building partnerships with faith-based organizations to foster vaccine acceptance.\u003c/p\u003e"},{"header":"10. Application and Policy Connections:","content":"\u003cp\u003eThe robust methodology and findings from this study directly inform Uganda's 2025 Health Sector Development Plan (HSDP) goal of increasing adolescent immunization coverage. The detailed understanding of barriers across individual, health facility, and community levels provides a strong evidence base for targeted policy revisions and program adaptations, particularly concerning: strengthening cooperation between the education sector for school-based delivery; assisting VHTs with tracking and awareness initiatives for community outreach; and resolving obstacles for nomadic and out-of-school populations to ensure fair access. The methodological lessons learned can also serve as a blueprint for evaluating future public health interventions in the country.\u003c/p\u003e\u003cp\u003e\u003cb\u003eExample of an Implementation Framework: Making the Switch to Age-Based Vaccination\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eThis study's methodology could be applied to inform administrative changes by updating Ministry of Health and Education joint protocols and school records with birth dates to track eligibility. Capacity building for medical staff would involve teaching them how to verify age, and educating educators on new standards and referral channels. Monitoring coverage by age groups (lasting one year) and comparing uptake between girls who attend school and those who do not is essential. Launching trial projects in two to three districts could utilize aspects of this mixed-methods approach to assess reach, adoption, and sustainability using the RE-AIM paradigm, prior to nationwide implementation.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;This study was conducted in accordance with the Declaration of Uganda National Council for Science and Technology and all applicable ethical guidelines for research involving human participants. Clearance to conduct this study was obtained from the Department of community at Kable, under registration number 2018/MPH/1659/W. Further ethical approval was granted by office of District Health officer Rukiga District and final clearance for data collection was obtained from the Uganda National Council for Science and Technology (UNCST), reference number MUST-2022-511. Informed consent was obtained from all participants prior to their involvement in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe researchers obtained written consent to use quotes from participants in publications.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability:\u003c/strong\u003e The primary study document, including the detailed information and dataset used and analyzed and is available upon reasonable request from the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests:\u003c/strong\u003e The authors hereby declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;No external funding was received for this work\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ Contributions\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eMbonigaba Rukarama Evarist conceptualized the study, designed the study framework, led data collection and interpretation, prepared the manuscript, and reviewed the paper. He is the principal investigator. Ronald Arineitwe Kibonire, as co-author, provided guidance throughout the study's conception, design, data collection and analysis phases, reviewed the manuscript, and offered valuable feedback for refinement. He served as the co-investigator.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;We express our gratitude to the community of Rubanda for their participation in this study. Our sincere thanks go to the Office of the District Health Officer of Rukiga District for granting us permission to conduct the research in the district. We also extend special appreciation to the health facility staff of the selected facilities of Rukiga District and VHT members for their support in coordinating and mobilizing respondents for the study and even also giving their views as participants.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eDuncan, J., Harris, M., Skyers, N., Bailey, A., \u0026amp; Figueroa, J. P. (2021). A call for low-and middle-income countries to commit to the elimination of cervical cancer. \u003cem\u003eThe Lancet Regional Health\u0026ndash;Americas\u003c/em\u003e, \u003cem\u003e2\u003c/em\u003e.\u003c/li\u003e\n\u003cli\u003eAnumolu, N., Lechleitner, K., Patel, N., Mijumbi, A., Jankowski, C., Anguzu, R., ... \u0026amp; Beyer, K. 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Human papillomavirus (HPV) vaccine introduction in Sikkim state: Best practices from the first statewide multiple-age cohort HPV vaccine introduction in India\u0026ndash;2018\u0026ndash;2019. \u003cem\u003eVaccine\u003c/em\u003e, \u003cem\u003e40\u003c/em\u003e, A17-A25.\u003c/li\u003e\n\u003cli\u003eJahrami, H., Trabelsi, K., Saif, Z., Manzar, M. D., Bahammam, A. S., \u0026amp; Vitiello, M. V. (2023). Reliability generalization meta-analysis of the Athens Insomnia Scale and its translations: Examining internal consistency and test-retest validity. \u003cem\u003eSleep Medicine\u003c/em\u003e, \u003cem\u003e111\u003c/em\u003e, 133-145.\u003c/li\u003e\n\u003cli\u003eKarafillakis, E., Peretti-Watel, P., Verger, P., Chantler, T., \u0026amp; Larson, H. J. (2022). \u0026lsquo;I trust them because my mum trusts them\u0026rsquo;: exploring the role of trust in HPV vaccination decision-making among adolescent girls and their mothers in France. \u003cem\u003eVaccine\u003c/em\u003e, \u003cem\u003e40\u003c/em\u003e(8), 1090-1097.\u003c/li\u003e\n\u003cli\u003eBeyen, M. W. M., Bulto, G. A., Chaka, E. E., Debelo, B. T., Roga, E. Y., Wakgari, N., ... \u0026amp; Fekene, D. B. (2022). Human papillomavirus vaccination uptake and its associated factors among adolescent school girls in Ambo town, Oromia region, Ethiopia, 2020. \u003cem\u003ePloS one\u003c/em\u003e, \u003cem\u003e17\u003c/em\u003e(7), e0271237.\u003c/li\u003e\n\u003cli\u003eEdwin, R., Mackay, C., \u0026amp; Mda, S. (2022). Missed Opportunities: A Cross-Sectional Descriptive Study on Reasons for Nonadherence to the South African Expanded Program on Immunization. \u003cem\u003eJournal of Pediatric Infectious Diseases\u003c/em\u003e, \u003cem\u003e17\u003c/em\u003e(06), 282-288.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"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":"bmc-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcan","sideBox":"Learn more about [BMC Cancer](http://bmccancer.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcan/default.aspx","title":"BMC Cancer","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Mixed-methods research, cross-sectional study, HPV vaccination, research design, methodology, data collection, qualitative analysis, quantitative analysis, Uganda, public health","lastPublishedDoi":"10.21203/rs.3.rs-7444969/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7444969/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e\u003cp\u003eLow uptake of the Human Papillomavirus (HPV) vaccine series presents a persistent challenge in preventing cervical cancer in low-resource settings like Uganda. Effective interventions rely on a nuanced understanding of contributing factors. This paper outlines the comprehensive mixed-methods research approach and cross-sectional design employed to investigate factors associated with low HPV vaccine uptake among adolescent girls in Rukiga District, Uganda.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e\u003cp\u003eA convergent mixed-methods, cross-sectional design was utilized integrating quantitative and qualitative data collected concurrently between September and November 2022. The study involved 292 caregivers of adolescent girls and 21 key informants (health workers and Village Health Team members) in Rukiga District. A multi-stage sampling technique ensured representativeness for quantitative data. Quantitative data collected via semi-structured questionnaires were analyzed using descriptive statistics, bivariate analysis, and multivariable logistic regression in SPSS. Qualitative data, gathered through in-depth interviews, underwent thematic analysis. Robust measures for validity (content, construct, face, member checking) and reliability (Cronbach\u0026rsquo;s alpha, test-retest, intercoder reliability) were implemented to ensure data quality and trustworthiness.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe mixed-methods approach successfully facilitated the collection of both statistical insights into vaccination rates and an in-depth understanding of underlying beliefs, barriers, and facilitators. The quantitative component provided measurable associations between various factors and HPV uptake while the qualitative component offered rich contextual explanations for these relationships highlighting the \"how\" and \"why\" behind observed trends.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe employed mixed-methods cross-sectional design proved effective in comprehensively investigating the complex factors influencing HPV vaccine uptake in a rural Ugandan setting. This methodological approach allowed for triangulation of data, enhancing the validity and depth of findings. Lessons learned from this design can inform future research aiming to understand multi-faceted public health challenges in similar contexts.\u003c/p\u003e","manuscriptTitle":"Designing for insight. A Mixed-Methods Approach to Unpacking HPV Vaccine Uptake in Rural Uganda","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-15 08:13:55","doi":"10.21203/rs.3.rs-7444969/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-10-08T19:11:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"245069849204107567649735930469548507598","date":"2025-09-28T10:43:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"176700711726415981022392101632039455706","date":"2025-09-24T14:25:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"82837579103658369967337350549960207960","date":"2025-09-19T20:20:17+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-18T14:56:29+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-08-29T17:19:06+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-27T22:54:46+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-27T22:53:53+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Cancer","date":"2025-08-24T08:23:44+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcan","sideBox":"Learn more about [BMC Cancer](http://bmccancer.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcan/default.aspx","title":"BMC Cancer","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f3c4450f-c747-4f20-82ab-e2b245db1b8d","owner":[],"postedDate":"September 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-09-18T15:08:25+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-15 08:13:55","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7444969","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7444969","identity":"rs-7444969","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}