Factors Associated with Low Uptake of Human Papilloma Virus (HPV) Vaccination Series in Adolescent Girls in Rukiga District, Uganda

Factors Associated with Low Uptake of Human Papilloma Virus (HPV) Vaccination Series in Adolescent Girls in Rukiga District, Uganda | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Factors Associated with Low Uptake of Human Papilloma Virus (HPV) Vaccination Series in Adolescent Girls in Rukiga District, Uganda Mbonigaba Rukarama Evarist, Ronald Arineitwe Kibonire This is a preprint; it has not been peer reviewed by a journal.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-7394339/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 4 You are reading this latest preprint version Abstract Background This study investigated the low completion rates of the HPV vaccine series in Rukiga District, Uganda, a critical step for cervical cancer prevention. Methods A mixed-methods, cross-sectional study was conducted which included a final sample of 292 parents or caregivers of adolescent girls. Researchers used multivariate logistic regression to identify determinants of completing the two-dose regimen and conducted in-depth interviews with 11 health workers involved in immunisationand 10 Village Health Team members to explore barriers. Results Only 27.49% of eligible girls completed the two-dose series. Girls with mothers as caregivers had greater odds of completion (AOR = 1.70, 95% CI: 1.05-2.74, p = 0.030). Caregivers without formal education were less likely to vaccinate their daughters (AOR = 0.19, 95% CI: 0.05-0.74, p = 0.033). Awareness of HPV infection was a powerful predictor of uptake (AOR = 4.65, 95% CI: 2.03-10.66, p < 0.001). Qualitative data highlighted barriers including vaccine safety misinformation, insufficient health worker training, stockouts, long wait times, and community distrust. Conclusion The low HPV vaccine completion rate is attributed to a combination of caregiver knowledge gaps, socioeconomic obstacles, and systemic health service limitations. Community mistrust and misinformation further exacerbate the issue. Interventions should be integrated to address both supply and demand-side barriers, increase health worker capacity, and rebuild community trust. HPV vaccination low uptake adolescent girls Rukiga District Uganda caregivers health system barriers community factors knowledge attitudes Introduction Cervical cancer is a significant global public health issue particularly in low- and middle-income nations, where 90% of deaths occur [ 1 , 2 ]. It is the fourth most frequent cancer in women worldwide with Human Papillomavirus (HPV) being the most common cause [ 3 , 4 , 5 , 6 , 7 ]. High-risk HPV forms 16 and 18 are linked to nearly 70% of cervical cancer occurrences [ 3 , 4 , 5 ]. In Uganda, cervical cancer is the leading cause of cancer-related death in women, accounting for nearly 40% of all female cancer cases [ 8 , 9 ]. Uganda's age-standardized cervical cancer incidence and mortality rates are 56.7 and 40.1 per 100,000 women, respectively, which are significantly higher than global standards [ 10 , 11 , 12 , 13 ]. Uganda initiated its first HPV vaccine demonstration program in 2006, and the HPV vaccination was officially included in the nationwide routine immunization program in 2015 [ 14 ]. While the first dose has been well-received, completion of the two-dose schedule remains poor, with national health data showing a constant fall between the first and second doses [ 15 , 16 ]. In Rukiga District, HPV1 adoption has remained quite high, but the second dose absorption has fallen dramatically, with recent data indicating a dropout rate of 23.49% [ 17 ]. This is concerning because complete protection against HPV requires completion of the two-dose regimen in adolescent females aged 9 to 14 years [ 16 ]. The rationale for this study was to understand the underlying causes of low HPV vaccine uptake in high-burden rural communities like Rukiga to inform targeted initiatives. Methods 2.1 Research Approach and Study Design This study employed a cross-sectional mixed-methods approach, combining quantitative and qualitative data collection to comprehensively assess HPV vaccination uptake [18,19.20]. The cross-sectional design was chosen for its efficiency in assessing relationships between variables at a single point in time. 2.2 Study Setting and timing The study was conducted in Rukiga District, Uganda, which spans 426.3 km² and has a population of approximately 132,355 people with a density of 268 persons per km² [ 21 ]. The district shares borders with Ntungamo, Kabale, Rubanda, and Rukungiri districts, as well as with the Republic of Rwanda. Muhanga, the largest town in Rukiga, is located about 35.5 kilometers northeast of Kabale and 374 kilometers southwest of Kampala, the capital city of Uganda. This cross-sectional study took place between September and November 2022 and aimed to assess HPV vaccination uptake and associated factors among adolescent girls at a single point in time. 2.3 Study Population Both the quantitative and qualitative aspects of the study involved clearly defined populations. The quantitative component targeted parents and guardians of adolescent girls aged 9–14 years, who are the primary decision-makers for HPV vaccination uptake [ 22 , 23 ]. In contrast, the qualitative component engaged health workers and Village Health Team (VHT) members as key informants, given their critical roles in vaccine implementation, service delivery, and community outreach within the district [ 24 ]. This dual approach ensured that perspectives were captured from both those making vaccination decisions and those facilitating the vaccination process. 2.3.1 Sampling and Sample Size ddetermination A multistage sampling approach was employed to select participants. Two sub-counties with low HPV vaccination coverage and accessibility challenges were purposively chosen, after which parishes and villages within them were randomly selected. Households with eligible adolescent girls were proportionally chosen based on village size and then systematically sampled, yielding 292 parents or caregivers for the quantitative survey. For the qualitative component, 11 health workers involved in the Expanded Programme on Immunization (EPI) and HPV vaccination, along with 10 Village Health Team (VHT) members from the selected villages, were purposively sampled to provide in-depth contextual insights. The quantitative sample size was determined using Cochran’s formula for an infinite population (n₀ = Z²pq / e²), where Z = 1.96 (95% CI), p = 0.5 (maximum variability), q = 1 - p, and e = 0.05 (desired precision), giving n₀ = 385. This was then adjusted for a finite population of N = 1,200 households using the correction formula (n = n₀ / [1 + (n₀ − 1) / N]), resulting in an adjusted sample size of approximately 292 households. This figure was adopted for the study to ensure both statistical reliability and feasibility. 2.3.2 Inclusion and Exclusion Criteria: The study involved parents or primary caregivers of adolescent girls aged 9–14 years from selected sub-counties in Rukiga District who gave informed consent, excluding those with cognitive or hearing impairments and child-headed households. 2.4 Study Variables: The dependent variable was low completion rates of the two-dose HPV vaccine in Rukiga District, Uganda.Independent variables included barriers at three levels: individual, health facility, and community. Individual barriers consisted of inadequate knowledge, absenteeism, dropping out of school, change of residence, poor infrastructure, fear of injection, caregiver discouragement, and peer discouragement. Health facility barriers included poor documentation, limited knowledge among service providers, lack of strategies targeting out-of-school girls, vaccine supply shortages, limited social mobilization, unreliable transportation, lack of staff motivation, and shortage of healthcare workers. Community-level barriers encompassed rumors or false beliefs, religion and traditional values, extended long wait times for adolescents, busy schedules, and mistrust of government motives. 2.5 Data Collection Methods A mixed-methods approach was employed, combining semi-structured questionnaires for quantitative data and Key Informant Interviews for qualitative insights. Interview guides were developed from existing literature, translated into local languages, and pre-tested in a similar community to ensure clarity and cultural relevance. Ten trained research assistants with relevant language skills and medical backgrounds conducted household visits, supervised daily for quality assurance. Data collection utilized pre-tested tools, with daily field editing to maintain accuracy and completeness. 2.6 Validity and Reliability of the Research Instrument: Data quality was maintained through rigorous validity and reliability measures for both quantitative and qualitative data. Quantitative validity was ensured through expert consultation, literature review, and pilot testing, with face validity supported by input from Village Health Team members on clarity and cultural appropriateness. Reliability was confirmed by strong internal consistency with Cronbach’s alpha ranging from 0.72 to 0.83 and test-retest reliability of 0.82 as reported by [ 25 ]. For qualitative data, validity was enhanced through member checking with participants, while reliability was reinforced through intercoder agreement achieved by independent coding and consensus among researchers. 2.7 Data Quality Control Data quality was ensured through adequate questionnaire use, careful identification of key informants, and thorough training of research assistants. The data collection process was supervised, reviewed regularly, and data were systematically entered. A pretest of the questionnaire was conducted to validate its clarity and effectiveness. 2.8 Data Management and Analysis 2.8.1 Quantitative Data Analysis Data were checked for completeness, entered into Epi-Info, transferred to SPSS, and analyzed. Descriptive statistics and frequency tables were generated through univariate analysis. Bivariate analysis assessed associations using confidence intervals and p-values. Multivariable logistic regression included all variables from the bivariate stage to control for confounding and identify factors associated with HPV vaccine uptake, ensuring important variables were not excluded prematurely. 2.8.2 Qualitative Data Analysis Open-ended responses were coded into common themes to facilitate structured interpretation. This thematic approach transformed unstructured data into clear categories, enabling identification of key trends and enhancing the depth and reliability of the qualitative analysis. 2.9 Ethical considerations Permission to conduct the study on factors associated with low uptake of the Human Papilloma Virus (HPV) vaccine among adolescent girls was obtained from the Mbarara University of Science and Technology Research Ethics Committee (REC No. MUST-2022-511). Administrative clearance was also secured from the District Health Officer. Written informed consent was obtained from the mothers or primary caregivers of the eligible girls for vaccination, who were then interviewed as part of the data collection process. Participant information was handled with strict confidentiality throughout the study. All research procedures were conducted in accordance with the Declaration of Helsinki. Results 3.1 Demographic Characteristics of the Respondents: Of the 292 respondents, 42.8% were aged 41–50, and 36.6% were 31–40 years old. All participants were from rural areas (100%). The majority were female (93.5%), mothers (72.9%), peasants (80.8%), and married (84.9%). Most adolescent daughters were aged 11–13 (60.3%), followed by those aged 14–15 years (21.9%). These demographic characteristics are summarized in Table 1 . Table 1 Demographic characteristics of the respondents Characteristics Category n % Age 20–30 35 12.0 31–40 107 36.6 41–50 125 42.8 50 above 25 8.6 Daughter’s age 8–10 46 15.8 11–13 176 60.3 14–15 64 21.9 16–18 6 2.1 Area of residence Rural 292 100 Gender of the caretaker Male 19 6.5 Female 273 93.5 Caretaker relationship Mother 213 72.9 Grandparent 17 5.8 House help or maid 10 3.4 Father 19 6.5 Aunt 5 1.7 Brother 6 2.1 Sister 22 7.5 Education level None 8 2.7 Primary 192 68.8 Secondary 68 23.3 Tertiary 24 8.2 Occupation of the parent caretaker Peasant 236 80.8 Business 31 10.6 Employed 20 6.8 Maid 5 1.7 Marital status Single 20 6.8 Married 248 84.9 Divorced 19 6.5 Widow 5 1.7 3.2 Distance from the Health Center A majority of respondents (70.5%) lived 1–3 kilometers from a health center, while 20.2% lived 4–6 kilometers away, and 8.2% lived more than 6 kilometers away. 3.3 Class Attended by the Children The majority of girls were in Primary Four (36.6%), followed by Primary Five (21.2%) and Primary Three (20.9%). 3.4 Individual Factors Associated with Low Uptake: Analysis of individual-level variables showed that HPV vaccine uptake varied with several behavioral and logistical factors. For example, 70.9% of caregivers reported that inadequate knowledge about HPV contributed to low uptake. Similarly, 62.3% of adolescent girls reportedly refused vaccination due to caregiver discouragement. Other barriers included poor road access, cited by 71.6% of respondents, fear of injection (68.8%), absenteeism or school dropout (59.9%), and discouragement from peers or caregivers (67.5%). Details of these distributions and associations are presented in Table 2 . Table 2 Individual factors associated with low uptake of the Human Papilloma Virus vaccine series Statement Variable option n (%) Inadequate knowledge about Human PapillomaVirus (HPV) can lead to low uptake. Yes 207 (70.9) No 85 (29.1) Change of residence from one location to another may lead to low uptake of the Human PapillomaVirus vaccine. Yes 110 (37.7) No 182 (62.3) Absenteeism and dropout from school Yes 175 (59.9) No 117 (40.1) Girls at the age of vaccination refuse to get vaccinated due to discouragement from caregivers. Yes 182 (62.3) No 110 (37.7) Poor roads that limit access to some schools may limit routine childhood vaccination. Yes 209 (71.6) No 83 (28.4) Fear of injection may discourage eligible children from getting vaccinated. Yes 201 (68.8) No 91 (31.2) Discouragement from vaccination by caregivers or peers. Yes 197 (67.5) No 95 (32.5) Source: Primary data, 2022 3.5 Health Factors Associated with Low Uptake Health system challenges were major barriers to HPV vaccine uptake. Specifically, 66.4% of respondents reported poor records management, 65.4% noted limited health worker knowledge of the HPV vaccination schedule, and 67.8% indicated a lack of government programs targeting out-of-school girls. Vaccine shortages and inadequate cold chain infrastructure were cited by 66.1%, untimely transportation of staff by 73.3%, low staff motivation by 73.6%, and understaffing of healthcare workers by 57.5%. These factors collectively constrained access to vaccination services, as summarized in Table 3 below. Table 3 Health factors associated with low completion rates of the two-dose HPV vaccine Statement Variable option n (%) Poor records management. Yes 194 (66.4) No 98 (33.6) Limited knowledge of HPV vaccination schedule Yes 191 (65.4) No 101 (34.6) Lack of clear programs by the government which target girls out of school. Yes 198 (67.8) No 94 (32.2) Shortage of vaccines and inadequate cold chain infrastructure. Yes 193 (66.1) No 99 (33.9) Uuntimely transportation of staff to vaccination centre Yes 214 (73.3) No 78 (26.7) Lack of staff motivation such as the outreach allowances. Yes 215 (73.6) No 77 (26.4) Understaffing of healthcare workers Yes 168 (57.5) No 124 (42.5) Source: Primary data, 2022 3.6 Community Factors Associated with Low Uptake Analysis of community-related factors revealed several barriers to HPV vaccine uptake. A majority of respondents (67.8%) indicated that circulating rumors and misconceptions negatively affected vaccination. Similarly, 60.3% reported that religious and cultural opposition, as well as mistrust in government programs, discouraged vaccination. Practical constraints, such as busy schedules of stakeholders (60.6%) and prolonged waiting times at vaccination centers (63.4%), were also identified as significant impediments. These distributions are presented in Table 4 below. Table 4 Community factors completion rates of the two-dose HPV vaccine Statement Variable option n (%) Low uptake can result from rumors or misconceptions. Yes 198 (67.8) No 94 (32.2) Religious and cultural anti-vaccination sentiments. Yes 176 (60.3) No 116 (39.7) Mistrust of government intentions. Yes 176 (60.3) No 116 (39.7) Busy schedules by the stakeholders (health workers, VHTs, and Teachers) Yes 177 (60.6) No 115 (39.4) Long waiting times for girls at vaccination centre Yes 185 (63.4) No 107 (36.6) Source: Primary data, 2022 3.7 Knowledge of Human Papilloma Virus : The completion rate for the two-dose HPV vaccination series was 27.49%. Most respondents (92.1%) had information about HPV, primarily from health workers (33.6%). While 58.2% correctly identified the eligible age (9–14 years), a significant knowledge gap existed regarding the number of doses, with 53.4% incorrectly believing only one dose was required. Consequently, 51.0% reported their daughters received only one dose. 3.8 Attitude Towards HPV Vaccines 64.7% of respondents agreed the HPV vaccine is very expensive, while 79.1% believed it effectively protects against HPV. 3.9 Bivariate Analysis of Key Variables Demographic Characteristics Daughter's age had a significant impact, with girls aged 11–13 twice as likely to have received the vaccine as those aged 8–10 (COR = 2.01; 95% CI: 1.10–3.67; p = 0.023). Employed caregivers showed a borderline significance with higher uptake (COR = 2.23; p = 0.076). Higher education levels were associated with greater vaccination probabilities, though not statistically significant. Distance from Health Center No significant correlation was found between distance and HPV vaccine uptake. Class Attended No significant correlation was found between school class and HPV vaccine uptake. Individual Factors Change of residence (OR = 0.50, p = 0.001) and school absenteeism (OR = 0.73, p = 0.037) were significantly linked with lower odds of HPV vaccine completion. Other individual factors were not statistically significant. Health Facility Factors Limited knowledge of HPV vaccination schedule by health workers (OR = 0.94, p = 0.043) and lack of clear government programs targeting out-of-school girls (OR = 0.97, p = 0.035) were associated with lower risks of poor uptake. Conversely, understaffing (OR = 1.967, p = 0.006) and vaccine shortages/inadequate cold chain infrastructure (OR = 1.748, p = 0.004) significantly raised the likelihood of low uptake. Community Factors Rumors/misconceptions (OR = 1.45, p = 0.033), religious/cultural anti-vaccination sentiments (OR = 1.59, p = 0.031), and mistrust of government intentions (OR = 1.80, p = 0.009) were significantly linked to low uptake. Long waiting times were surprisingly linked to a decrease in low uptake (OR = 0.75, p = 0.046). Knowledge Related Factors Hearing about HPV (OR = 4.65, p = 0.001), knowing the eligible age (OR = 2.29, p < 0.001), believing vaccination is right (OR = 3.57, p = 0.003), and knowing the correct number of doses (OR = 2.20, p = 0.005) were significantly associated with higher uptake. 3.10 Multivariable Logistic Regression Analysis Table 5 Multivariable Logistic Regression Analysis of Factors Associated with low completion rates of the two-dose HPV vaccine in Rukiga District, Uganda. Factor Variable Option n AOR (95% CI) p-value Demographic Factors Caretaker Relationship: Mother 128 1.70 (1.05–2.75) 0.030 Education Level: None 2 0.19 (0.04–0.87) 0.033 Education Level: Primary 96 0.50 (0.30–0.83) 0.007 Occupation: Peasant 111 0.49 (0.28–0.87) 0.013 Individual Factors Change of residence: Yes 110 0.50 (0.37–0.69) 0.001 Absenteeism / dropout: Yes 175 0.73 (0.59–0.91) 0.037 Health System Factors Limited knowledge by health workers: Yes 191 0.94 (0.70–1.24) 0.043 No gov’t program for out-of-school girls: Yes 198 0.97 (0.73–1.29) 0.035 Shortage / cold chain issues: Yes 193 1.75 (1.04–2.93) 0.004 Understaffing: Yes 168 1.97 (1.05–3.68) 0.006 Community Factors Rumors / misconceptions: Yes 198 1.45 (1.03–2.04) 0.033 Religious/cultural opposition: Yes 176 1.59 (1.04–2.42) 0.031 Mistrust of government: Yes 176 1.80 (1.16–2.79) 0.009 Long waiting time: Yes 185 0.75 (0.57–0.98) 0.046 Knowledge Factors Heard about HPV: Yes 269 4.65 (1.89–11.45) 0.001 Knowledge of eligible age (9–14 yrs): Correct 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 (2 doses): Correct 74 2.20 (1.25–3.88) 0.005 Note. AOR = Adjusted Odds Ratio; CI = Confidence Interval. Bolded values indicate statistically significant associations (p < 0.05). The results of the multivariate logistic regression analysis (Table 5 ) identified key factors associated with low HPV vaccine uptake among adolescent girls. Demographically, daughters with mothers as primary caretakers were more likely to miss vaccination (AOR = 1.70; p = 0.030), while caretakers with no formal education (AOR = 0.19; p = 0.033) or only primary education (AOR = 0.50; p = 0.007) and those in peasant occupations (AOR = 0.49; p = 0.013) were less likely to have daughter’s complete vaccination. At the individual level, girls who changed residence (AOR = 0.50; p = 0.001) or experienced absenteeism/dropout (AOR = 0.73; p = 0.037) had lower uptake. Health system constraints, including vaccine shortages/cold chain issues (AOR = 1.75; p = 0.004) and understaffing (AOR = 1.97; p = 0.006), also significantly affected completion. Community-level barriers, notably rumors/misconceptions (AOR = 1.45; p = 0.033), religious/cultural opposition (AOR = 1.59; p = 0.031), and mistrust of government (AOR = 1.80; p = 0.009), were associated with low uptake. Conversely, caregiver knowledge strongly facilitated vaccination: awareness of HPV (AOR = 4.65; p = 0.001), correct eligible age (AOR = 2.29; p < 0.001), belief in vaccination (AOR = 3.57; p = 0.003), and knowledge of the two-dose schedule (AOR = 2.20; p = 0.005) significantly improved completion. These findings indicate that low HPV vaccine uptake in Rukiga District is influenced by a combination of caregiver characteristics, individual behaviors, health system limitations, community perceptions, and knowledge gaps, emphasizing the need for integrated interventions targeting both awareness and service delivery. 3.11 Qualitative Data Analysis (Thematic Presentation): Individual-Level Barriers Included lack of awareness about vaccination eligibility and purpose, school absenteeism (due to fees, household responsibilities, early menstruation, farm work), frequent family relocation and school transfers disrupting follow-ups, physical barriers (poor road networks), fear of injection pain, and negative influence from caregivers or peers (misconceptions, adverse effect stories). Health Facility Barriers Included limited knowledge among healthcare workers, VHTs, and teachers about HPV vaccination guidelines, cold chain and logistical challenges (shortages of ice packs, lack of refrigeration), inadequate community engagement and mobilization (seasonal activities preventing access to information), transportation challenges (unreliable transport, canceled sessions), expectations of monetary incentives (demotivation of staff), staff shortages, and unfriendly behavior from healthcare workers. Community Level Barriers Included rumors and misconceptions (vaccine promoting early sexual activity, infertility concerns, HIV content), traditional and religious beliefs (vaccination contradicting cultural/religious norms) and lack of successful sensitization campaigns leading to community skepticism. Discussion The low HPV vaccine series uptake in adolescent girls in Rukiga District is a complex issue driven by a combination of demographic, individual, health system, and community factors, consistent with the Health Belief Model (HBM) [15] 4.1 Caregiver Relationship and Gender : Maternal involvement significantly boosts HPV vaccine uptake in adolescent girls aligning with HBM's cues to action and self-efficacy constructs. This finding is consistent with prior research emphasizing maternal influence [26, 27]. However, socioeconomic factors can moderate this influence as seen in lower HPV vaccination uptake among girls with single mothers in other regions. This suggests a need for targeted interventions that empower mothers through education and address structural barriers in vulnerable households. 4.2 Caregiver Education and Occupation : Higher caregiver education is strongly linked to increased HPV vaccination uptake in adolescent girls as educated caregivers are better equipped to understand health information and vaccination benefits, reflecting reduced perceived barriers and increased self-efficacy in the HBM [15, 26]. Occupation also plays a role, with peasant farmers having lower uptake of HPV vaccination in adolescent girls likely due to economic constraints and lower health literacy reinforcing perceived obstacles [28]. These findings underscore the need for accessible, culturally appropriate health education and flexible vaccination hours for low-literacy and working populations. 4.3 Class Grade Absenteeism and Change of Residence : School-based programs are effective, with Primary Four girls showing the highest HPV vaccination uptake in adolescent girls [29]. However, absenteeism, school dropout and residential mobility significantly hinder completion of the vaccine series by disrupting exposure to vaccination cues and undermining confidence in multi-dose regimens [30]. This highlights a need for flexible vaccination strategies, catch-up clinics, and interoperable digital health records to track mobile populations and ensure continuity of care. 4.4 Distance and Transport : Surprisingly, distance from health facilities was not a significant barrier suggesting the effectiveness of school-based and community outreach programs in bridging geographic gaps in low HPV vaccination uptake in adolescent girls [15, 31]. However, qualitative data indicated that poor infrastructure can still pose challenges emphasizing the importance of sustained investment in decentralized outreach efforts [32]. 4.5 Health Facility Factors: Logistics, Staffing, and Waiting Times : Logistical issues, such as vaccine stockouts and inadequate cold chain infrastructure, significantly impede vaccine uptake in adolescent girls by frustrating caregivers and eroding trust. Understaffing further exacerbates these issues by disrupting service delivery [15, 16, 28]. These systemic weaknesses increase perceived barriers and undermine cues to action within the HBM. Efforts to strengthen supply chain management, invest in infrastructure and prioritize recruitment and retention of healthcare workers are critical. While long waiting times were unexpectedly associated with lower missed HPV vaccinations in adolescent girls suggesting high caregiver motivation, improving clinic workflow remains important [15]. 4.6 Community Trust and Cultural Opposition : Mistrust in government and health systems, fueled by misinformation and conspiracy theories, significantly contributes to low HPV vaccine uptake in adolescent girls [33]. Religious and cultural resistance also acts as a barrier by diminishing perceived benefits and increasing perceived threat [15, 34]. Conversely, engaging trusted religious leaders can significantly improve HPV vaccine acceptance by serving as powerful cues to action. Transparent, culturally sensitive communication strategies are essential to rebuild trust and combat misinformation. 4.7 Knowledge, Attitudes and Misinformation : Parental knowledge of HPV and vaccination benefits is a powerful predictor of uptake, increasing perceived benefits, reducing barriers, and boosting self-efficacy [35–38]. Misinformation, including fear of injection pain and peer influence, reduces confidence and creates perceived barriers to low uptake of HPV vaccination in adolescent girls [15, 34, 39]. This highlights the need for structured community education, myth-busting campaigns, and school-based sensitization to foster positive vaccine attitudes and effectively translate awareness into action [40]. Conclusion Low HPV vaccine series completion in Rukiga District is primarily driven by caregiver knowledge gaps, socioeconomic disparities, and systemic limitations in health service delivery. Community mistrust and misinformation exacerbate these challenges. Addressing these complex issues requires integrated interventions that target both demand-side (e.g., education, trust-building) and supply-side (e.g., infrastructure, staffing) barriers. Prioritizing these strategies will significantly contribute to reducing the burden of HPV-related diseases and protecting adolescent health in Uganda. Recommendations Improving HPV vaccination uptake requires a comprehensive strategy that begins with targeted training for healthcare workers and Village Health Teams (VHTs) on delivering culturally sensitive campaigns. These efforts should be supported by simplified, low-literacy materials and active follow-up in schools and communities. Medium-term priorities include implementing an age-based policy, strengthening cold chain and tracking systems, and aligning vaccination schedules with local calendars. Engaging religious and community leaders is crucial for building trust and ensuring success. Assigning clear roles to the Ministry of Health, healthcare workers, schools and VHTs, along with using multiple reminder methods, will strengthen collaboration and community trust. Continuous monitoring and adaptation of these strategies will be key to sustaining high vaccination coverage over time. Abbreviations AOR Adjusted Odds Ratio COR Crude Odds Ratio EPI Expanded Programme on Immunization and vaccination HBM Health Belief Model HPV Human Papilloma Virus MUST Mbarara University of Science and Technology UNCST Uganda National Council for Science and Technology OR Odds Ratio REC Research Ethics Committee SPSS Statistical Package for the Social Sciences VHT Village Health Team Declarations 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. Acknowledgements We express our gratitude to the community of Rukiga 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. Funding No external funding was received for this work Author information Authors and Affiliations Mbonigaba Rukarama Evarist and Ronald Arineitwe Kibonire, Department of community Health, School of medicine Kable university, Kabale District, Kampala city, Uganda Contributions Mbonigaba Rukarama Evarist (MRE) conceptualized the study, designed the study framework, led data collection and interpretation, prepared the manuscript and the paper. He is the principal investigator. Ronald Arineitwe Kibonire (RAK) as co-author provided guidance throughout the study's conception, design, data collection, analysis phases, participated in paper writing, reviewed the manuscript and offered valuable feedback for refinement. He served as the co-author. Corresponding author Correspondence to Mbonigaba Rukarama Evarist. Ethics Approval and Consent to Participate This study was conducted in accordance with the Declaration of Helsinki and all applicable ethical guidelines for research involving human participants. Clearance to conduct this study was obtained from the Department of community of Kabale University 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. Informed consent was obtained from all participants. Care was taken to ensure the anonymity of participants as no names or otherwise identifying information were included in the data. Efforts were also made to prevent either physical or psychological harm or distress to the participants during and after interviewing them. Competing interests The authors hereby declare that they have no competing interests. References Reza S, Anjum R, Khandoker RZ, Khan SR, Islam MR, Dewan SMR. Public health concern-driven insights and response of low-and middle-income nations to the World health Organization call for cervical cancer risk eradication. Gynecologic Oncol Rep. 2024;54:101460. Rayner M, Welp A, Stoler MH, Cantrell LA. Cervical cancer screening recommendations: now and for the future. Healthcare. Volume 11. MDPI; 2023, August. p. 2273. 16. Su P, Ma J, Yu L, Tang S, Sun P. 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Global landscape of cervical cancer incidence and mortality in 2022 and predictions to 2030: The urgent need to address inequalities in cervical cancer. Int J Cancer. 2025;157(2):288–97. Obol JH, Lin S, Obwolo MJ, Harrison R, Richmond R. Provision of cervical cancer prevention services in Northern Uganda: a survey of health workers from rural health centres. BMC Health Serv Res. 2021;21(1):794. Laban M, Nanyonjo G, Wambuzi M, Ssetaala A, Basalirwa G, Muramuzi D, Mirzazadeh A. (2024). Uptake of Human Papilloma Virus vaccine among young women living in fishing communities in Wakiso and Mukono districts, Uganda. PLOS Global Public Health, 4(4), e0003106. Rujumba J, Akugizibwe M, Basta NE, Banura C. 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. 2021;16(6):e0253735. Patrick L, Bakeera-Kitaka S, Rujumba J, Malande OO. (2022). Encouraging improvement in HPV vaccination coverage among adolescent girls in Kampala, Uganda. PLoS ONE, 17(6), e0269655. District Health Information Software 2 (DHIS2). Rukiga District HPV vaccination data. Ministry of Health, Uganda; 2024. Wang W, Kothari S, Baay M, Garland SM, Giuliano AR, Nygård M, Sundström K. Real-world impact and effectiveness assessment of the quadrivalent HPV vaccine: a systematic review of study designs and data sources. Expert Rev Vaccines. 2022;21(2):227–40. Agimas MC, Adugna DG, Derseh NM, Kassaw A, Kassie YT, Abate HK, Mekonnen CK. Uptake of human papilloma virus vaccine and its determinants among females in East Africa: a systematic review and meta-analysis. BMC Public Health. 2024;24(1):842. Asgedom YS, Kebede TM, Seifu BL, Mare KU, Asmare ZA, Asebe HA, Kassie GA. Human papillomavirus vaccination uptake and determinant factors among adolescent schoolgirls in sub-Saharan Africa: A systematic review and meta-analysis. Hum vaccines immunotherapeutics. 2024;20(1):2326295. Rukiga NHPC. 2024. https://statistics.ubos.org/nphc/drilldown?subregion Jin SW, Lee Y, Brandt HM. Human papillomavirus (HPV) vaccination knowledge, beliefs, and hesitancy associated with stages of parental readiness for adolescent HPV vaccination: implications for HPV vaccination promotion. Trop Med Infect disease. 2023;8(5):251. Wijayanti KE, Schütze H, MacPhail C. Parents’ attitudes, beliefs and uptake of the school-based human papillomavirus (HPV) vaccination program in Jakarta, Indonesia–A quantitative study. Prev Med Rep. 2021;24:101651. Elit L, Ngalla C, Afugchwi GM, Tum E, Domgue JF, Nouvet E. 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. 2022;12(11):e068212. Jahrami H, Trabelsi K, Saif Z, Manzar MD, Bahammam AS, Vitiello MV. Reliability generalization meta-analysis of the Athens Insomnia Scale and its translations: Examining internal consistency and test-retest validity. Sleep Med. 2023;111:133–45. 8, Elenwo C, Batioja K, Davis T, Greiner BH, Markey C, Hartwell M. Associations of maternal age, education, and marital status with HPV vaccine uptake and hesitancy among United States youth: a cross-sectional analysis of the 2020 National Immunization Survey. J Pediatr Adolesc Gynecol. 2023;36(3):273–9. Lubeya MK, Chibwesha CJ, Mwanahamuntu M, Mukosha M, Maposa I, Kawonga M. Correlates of parental consent to human Papillomavirus vaccine uptake by their adolescent daughters in ZAMBIA: application of the health belief model. Vaccines. 2023;11(5):912. Rivera AF, Dussault JM, Doglioni O, Chyderiotis D, Sicsic S, Barret J, Mueller AS, J. E. Sociodemographic determinants of HPV vaccine awareness, uptake, and intention among parents of adolescents in France 2021-22. Hum vaccines immunotherapeutics. 2024;20(1):2381300. Holroyd TA, Yan SD, Srivastava V, Srivastava A, Wahl B, Morgan C, Jennings MC. Designing a pro-equity HPV vaccine delivery program for girls who have dropped out of school: community perspectives from uttar pradesh, India. Health Promot Pract. 2022;23(6):1039–49. Karanja-Chege CM. HPV vaccination in Kenya: the challenges faced and strategies to increase uptake. Front Public Health. 2022;10:802947. Egbon M, Ojo T, Aliyu A, Bagudu ZS. Challenges and lessons from a school-based human papillomavirus (HPV) vaccination program for adolescent girls in a rural Nigerian community. BMC Public Health. 2022;22(1):1611. Fish LJ, Harrison SE, McDonald JA, Yelverton V, Williams C, Walter EB, Vasudevan L. Key stakeholder perspectives on challenges and opportunities for rural HPV vaccination in North and South Carolina. Hum Vaccines Immunotherapeutics. 2022;18(5):2058264. Harrington N, Chen Y, O'Reilly AM, Fang CY. The role of trust in HPV vaccine uptake among racial and ethnic minorities in the United States: a narrative review. AIMS Public Health. 2021;8(2):352. Ochomo, E. O., Tonui, P., Muthoka, K., Amboka, S., Itsura, P., Orang’o, E. O., … Cu-Uvin,S. (2024). ‘Addressing HPV vaccine hesitancy: unveiling concerns and building trust’perspectives of adolescent girls and parents in Kisumu County, Kenya. ecancermedicalscience, 18, 1735.. Motilal, S., Mohepath, N., Moncur, J., Mohess, R., Mohan, V., Mohammed, S., … Mohess,R. A. (2023). Parental knowledge, attitudes, and perceptions impacting willingness to vaccinate against the human papillomavirus in Trinidad. Cureus, 15(8).. Akoro U, Stuart G, Stuart GP. (2024). Knowledge, Attitudes, and Perceptions of African Parents in New Zealand Towards the Human Papillomavirus Vaccine. Cureus, 16 (12). Naoum P, Athanasakis K, Zavras D, Kyriopoulos J, Pavi E. Knowledge, Perceptions and attitudes toward HPV vaccination: a survey on parents of girls aged 11–18 years old in Greece. Front Global Women's Health. 2022;3:871090. Smolarczyk K, Duszewska A, Drozd S, Majewski S. Parents’ knowledge and attitude towards HPV and HPV vaccination in Poland. Vaccines 10, no. 2 (2022): 228. Milondzo T, Meyer JC, Dochez C, Burnett RJ. Misinformation drives low human papillomavirus vaccination coverage in South African girls attending private schools. Front Public Health. 2021;9:598625. Bitariho GK, Tuhebwe D, Tigaiza A, Nalugya A, Ssekamatte T, Kiwanuka SN. Knowledge, perceptions and uptake of human papilloma virus vaccine among adolescent girls in Kampala, Uganda; a mixed-methods school-based study. BMC Pediatr. 2023;23(1):368. Additional Declarations No competing interests reported. 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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-7394339","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":503536273,"identity":"489084d6-901e-41ab-beee-eabddafab5d9","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":503536274,"identity":"145e3319-e9f2-441a-a151-6e7fcf54d9c0","order_by":1,"name":"Ronald Arineitwe Kibonire","email":"","orcid":"","institution":"Kabale University","correspondingAuthor":false,"prefix":"","firstName":"Ronald","middleName":"Arineitwe","lastName":"Kibonire","suffix":""}],"badges":[],"createdAt":"2025-08-17 20:53:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7394339/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7394339/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":89627218,"identity":"74af8086-eb63-44e0-bb89-4f1efcc43f1b","added_by":"auto","created_at":"2025-08-22 06:08:44","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1568639,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7394339/v1/92f7a701-9d0d-44fd-b881-81552cc61ca3.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Factors Associated with Low Uptake of Human Papilloma Virus (HPV) Vaccination Series in Adolescent Girls in Rukiga District, Uganda","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCervical cancer is a significant global public health issue particularly in low- and middle-income nations, where 90% of deaths occur [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. It is the fourth most frequent cancer in women worldwide with Human Papillomavirus (HPV) being the most common cause [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. High-risk HPV forms 16 and 18 are linked to nearly 70% of cervical cancer occurrences [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn Uganda, cervical cancer is the leading cause of cancer-related death in women, accounting for nearly 40% of all female cancer cases [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Uganda's age-standardized cervical cancer incidence and mortality rates are 56.7 and 40.1 per 100,000 women, respectively, which are significantly higher than global standards [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eUganda initiated its first HPV vaccine demonstration program in 2006, and the HPV vaccination was officially included in the nationwide routine immunization program in 2015 [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. While the first dose has been well-received, completion of the two-dose schedule remains poor, with national health data showing a constant fall between the first and second doses [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn Rukiga District, HPV1 adoption has remained quite high, but the second dose absorption has fallen dramatically, with recent data indicating a dropout rate of 23.49% [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. This is concerning because complete protection against HPV requires completion of the two-dose regimen in adolescent females aged 9 to 14 years [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The rationale for this study was to understand the underlying causes of low HPV vaccine uptake in high-burden rural communities like Rukiga to inform targeted initiatives.\u003c/p\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003cdiv id=\"Sec5\" class=\"Section3\"\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section3\"\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003cdiv id=\"Sec12\" class=\"Section3\"\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section3\"\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Methods","content":"\u003ch2\u003e2.1 Research Approach and Study Design\u003c/h2\u003e\u003cp\u003eThis study employed a cross-sectional mixed-methods approach, combining quantitative and qualitative data collection to comprehensively assess HPV vaccination uptake [18,19.20]. The cross-sectional design was chosen for its efficiency in assessing relationships between variables at a single point in time.\u003c/p\u003e\u003ch2\u003e2.2 Study Setting and timing\u003c/h2\u003e\u003cp\u003eThe study was conducted in Rukiga District, Uganda, which spans 426.3 km² and has a population of approximately 132,355 people with a density of 268 persons per km² [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The district shares borders with Ntungamo, Kabale, Rubanda, and Rukungiri districts, as well as with the Republic of Rwanda. Muhanga, the largest town in Rukiga, is located about 35.5 kilometers northeast of Kabale and 374 kilometers southwest of Kampala, the capital city of Uganda. This cross-sectional study took place between September and November 2022 and aimed to assess HPV vaccination uptake and associated factors among adolescent girls at a single point in time.\u003c/p\u003e\u003ch2\u003e2.3 Study Population\u003c/h2\u003e\u003cp\u003eBoth the quantitative and qualitative aspects of the study involved clearly defined populations. The quantitative component targeted parents and guardians of adolescent girls aged 9–14 years, who are the primary decision-makers for HPV vaccination uptake [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. In contrast, the qualitative component engaged health workers and Village Health Team (VHT) members as key informants, given their critical roles in vaccine implementation, service delivery, and community outreach within the district [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. This dual approach ensured that perspectives were captured from both those making vaccination decisions and those facilitating the vaccination process.\u003c/p\u003e\u003ch2\u003e2.3.1 Sampling and Sample Size ddetermination\u003c/h2\u003e\u003cp\u003eA multistage sampling approach was employed to select participants. Two sub-counties with low HPV vaccination coverage and accessibility challenges were purposively chosen, after which parishes and villages within them were randomly selected. Households with eligible adolescent girls were proportionally chosen based on village size and then systematically sampled, yielding 292 parents or caregivers for the quantitative survey. For the qualitative component, 11 health workers involved in the Expanded Programme on Immunization (EPI) and HPV vaccination, along with 10 Village Health Team (VHT) members from the selected villages, were purposively sampled to provide in-depth contextual insights.\u003c/p\u003e\u003cp\u003eThe quantitative sample size was determined using Cochran’s formula for an infinite population (n₀ = Z²pq / e²), where Z = 1.96 (95% CI), p = 0.5 (maximum variability), q = 1 - p, and e = 0.05 (desired precision), giving n₀ = 385. This was then adjusted for a finite population of N = 1,200 households using the correction formula (n = n₀ / [1 + (n₀ − 1) / N]), resulting in an adjusted sample size of approximately 292 households. This figure was adopted for the study to ensure both statistical reliability and feasibility.\u003c/p\u003e\u003ch2\u003e2.3.2 Inclusion and Exclusion Criteria:\u003c/h2\u003e\u003cp\u003eThe study involved parents or primary caregivers of adolescent girls aged 9–14 years from selected sub-counties in Rukiga District who gave informed consent, excluding those with cognitive or hearing impairments and child-headed households.\u003c/p\u003e\u003ch2\u003e2.4 Study Variables:\u003c/h2\u003e\u003cp\u003eThe dependent variable was low completion rates of the two-dose HPV vaccine in Rukiga District, Uganda.Independent variables included barriers at three levels: individual, health facility, and community. Individual barriers consisted of inadequate knowledge, absenteeism, dropping out of school, change of residence, poor infrastructure, fear of injection, caregiver discouragement, and peer discouragement. Health facility barriers included poor documentation, limited knowledge among service providers, lack of strategies targeting out-of-school girls, vaccine supply shortages, limited social mobilization, unreliable transportation, lack of staff motivation, and shortage of healthcare workers. Community-level barriers encompassed rumors or false beliefs, religion and traditional values, extended long wait times for adolescents, busy schedules, and mistrust of government motives.\u003c/p\u003e\u003ch2\u003e2.5 Data Collection Methods\u003c/h2\u003e\u003cp\u003eA mixed-methods approach was employed, combining semi-structured questionnaires for quantitative data and Key Informant Interviews for qualitative insights. Interview guides were developed from existing literature, translated into local languages, and pre-tested in a similar community to ensure clarity and cultural relevance. Ten trained research assistants with relevant language skills and medical backgrounds conducted household visits, supervised daily for quality assurance. Data collection utilized pre-tested tools, with daily field editing to maintain accuracy and completeness.\u003c/p\u003e\u003ch2\u003e2.6 Validity and Reliability of the Research Instrument:\u003c/h2\u003e\u003cp\u003eData quality was maintained through rigorous validity and reliability measures for both quantitative and qualitative data. Quantitative validity was ensured through expert consultation, literature review, and pilot testing, with face validity supported by input from Village Health Team members on clarity and cultural appropriateness. Reliability was confirmed by strong internal consistency with Cronbach’s alpha ranging from 0.72 to 0.83 and test-retest reliability of 0.82 as reported by [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. For qualitative data, validity was enhanced through member checking with participants, while reliability was reinforced through intercoder agreement achieved by independent coding and consensus among researchers.\u003c/p\u003e\u003ch2\u003e2.7 Data Quality Control\u003c/h2\u003e\u003cp\u003eData quality was ensured through adequate questionnaire use, careful identification of key informants, and thorough training of research assistants. The data collection process was supervised, reviewed regularly, and data were systematically entered. A pretest of the questionnaire was conducted to validate its clarity and effectiveness.\u003c/p\u003e\u003ch2\u003e2.8 Data Management and Analysis\u003c/h2\u003e\u003ch2\u003e2.8.1 Quantitative Data Analysis\u003c/h2\u003e\u003cp\u003eData were checked for completeness, entered into Epi-Info, transferred to SPSS, and analyzed. Descriptive statistics and frequency tables were generated through univariate analysis. Bivariate analysis assessed associations using confidence intervals and p-values. Multivariable logistic regression included all variables from the bivariate stage to control for confounding and identify factors associated with HPV vaccine uptake, ensuring important variables were not excluded prematurely.\u003c/p\u003e\u003ch2\u003e2.8.2 Qualitative Data Analysis\u003c/h2\u003e\u003cp\u003eOpen-ended responses were coded into common themes to facilitate structured interpretation. This thematic approach transformed unstructured data into clear categories, enabling identification of key trends and enhancing the depth and reliability of the qualitative analysis.\u003c/p\u003e\u003ch2\u003e2.9 Ethical considerations\u003c/h2\u003e\u003cp\u003ePermission to conduct the study on factors associated with low uptake of the Human Papilloma Virus (HPV) vaccine among adolescent girls was obtained from the Mbarara University of Science and Technology Research Ethics Committee (REC No. MUST-2022-511). Administrative clearance was also secured from the District Health Officer. Written informed consent was obtained from the mothers or primary caregivers of the eligible girls for vaccination, who were then interviewed as part of the data collection process. Participant information was handled with strict confidentiality throughout the study. All research procedures were conducted in accordance with the Declaration of Helsinki.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003e3.1 Demographic Characteristics of the Respondents:\u003c/h2\u003e\u003cp\u003eOf the 292 respondents, 42.8% were aged 41\u0026ndash;50, and 36.6% were 31\u0026ndash;40 years old. All participants were from rural areas (100%). The majority were female (93.5%), mothers (72.9%), peasants (80.8%), and married (84.9%). Most adolescent daughters were aged 11\u0026ndash;13 (60.3%), followed by those aged 14\u0026ndash;15 years (21.9%). These demographic characteristics are summarized in Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDemographic characteristics of the respondents\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristics\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCategory\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003en\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20\u0026ndash;30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e31\u0026ndash;40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e107\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e36.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e41\u0026ndash;50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e125\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e42.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e50 above\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eDaughter\u0026rsquo;s age\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8\u0026ndash;10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e15.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11\u0026ndash;13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e176\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e60.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14\u0026ndash;15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e21.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e16\u0026ndash;18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eArea of residence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRural\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e292\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e100\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eGender of the caretaker\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e273\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e93.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"6\" rowspan=\"7\"\u003e\u003cp\u003eCaretaker relationship\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMother\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e213\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e72.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGrandparent\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHouse help or maid\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFather\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAunt\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBrother\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSister\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eEducation level\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePrimary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e192\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e68.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSecondary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e68\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e23.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTertiary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eOccupation of the parent caretaker\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePeasant\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e236\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e80.8\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBusiness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEmployed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMaid\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eMarital status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSingle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e248\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e84.9\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDivorced\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWidow\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003e3.2 Distance from the Health Center\u003c/h2\u003e\u003cp\u003eA majority of respondents (70.5%) lived 1\u0026ndash;3 kilometers from a health center, while 20.2% lived 4\u0026ndash;6 kilometers away, and 8.2% lived more than 6 kilometers away.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003e3.3 Class Attended by the Children\u003c/h2\u003e\u003cp\u003eThe majority of girls were in Primary Four (36.6%), followed by Primary Five (21.2%) and Primary Three (20.9%).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003e3.4 Individual Factors Associated with Low Uptake:\u003c/h2\u003e\u003cp\u003eAnalysis of individual-level variables showed that HPV vaccine uptake varied with several behavioral and logistical factors. For example, 70.9% of caregivers reported that inadequate knowledge about HPV contributed to low uptake. Similarly, 62.3% of adolescent girls reportedly refused vaccination due to caregiver discouragement. Other barriers included poor road access, cited by 71.6% of respondents, fear of injection (68.8%), absenteeism or school dropout (59.9%), and discouragement from peers or caregivers (67.5%). Details of these distributions and associations are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eIndividual factors associated with low uptake of the Human Papilloma Virus vaccine series\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=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStatement\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eVariable option\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eInadequate knowledge about Human PapillomaVirus (HPV) can lead to low uptake.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e207 (70.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e85 (29.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eChange of residence from one location to another may lead to low uptake of the Human PapillomaVirus vaccine.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e110 (37.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e182 (62.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eAbsenteeism and dropout from school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e175 (59.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e117 (40.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eGirls at the age of vaccination refuse to get vaccinated due to discouragement from caregivers.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e182 (62.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e110 (37.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003ePoor roads that limit access to some schools may limit routine childhood vaccination.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e209 (71.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e83 (28.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eFear of injection may discourage eligible children from getting vaccinated.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e201 (68.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e91 (31.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eDiscouragement from vaccination by caregivers or peers.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e197 (67.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e95 (32.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003cb\u003eSource: Primary data, 2022\u003c/b\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003e3.5 Health Factors Associated with Low Uptake\u003c/h2\u003e\u003cp\u003eHealth system challenges were major barriers to HPV vaccine uptake. Specifically, 66.4% of respondents reported poor records management, 65.4% noted limited health worker knowledge of the HPV vaccination schedule, and 67.8% indicated a lack of government programs targeting out-of-school girls. Vaccine shortages and inadequate cold chain infrastructure were cited by 66.1%, untimely transportation of staff by 73.3%, low staff motivation by 73.6%, and understaffing of healthcare workers by 57.5%. These factors collectively constrained access to vaccination services, as summarized in Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e below.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eHealth factors associated with low completion rates of the two-dose HPV vaccine\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=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStatement\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eVariable option\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003ePoor records management.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e194 (66.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e98 (33.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eLimited knowledge of HPV vaccination schedule\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e191 (65.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e101 (34.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eLack of clear programs by the government which target girls out of school.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e198 (67.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e94 (32.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eShortage of vaccines and inadequate cold chain infrastructure.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e193 (66.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e99 (33.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eUuntimely transportation of staff to vaccination centre\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e214 (73.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e78 (26.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eLack of staff motivation such as the outreach allowances.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e215 (73.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e77 (26.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eUnderstaffing of healthcare workers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e168 (57.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e124 (42.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003cb\u003eSource: Primary data, 2022\u003c/b\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003e3.6 Community Factors Associated with Low Uptake\u003c/h2\u003e\u003cp\u003eAnalysis of community-related factors revealed several barriers to HPV vaccine uptake. A majority of respondents (67.8%) indicated that circulating rumors and misconceptions negatively affected vaccination. Similarly, 60.3% reported that religious and cultural opposition, as well as mistrust in government programs, discouraged vaccination. Practical constraints, such as busy schedules of stakeholders (60.6%) and prolonged waiting times at vaccination centers (63.4%), were also identified as significant impediments. These distributions are presented in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e below.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCommunity factors completion rates of the two-dose HPV vaccine\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=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStatement\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eVariable option\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eLow uptake can result from rumors or misconceptions.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e198 (67.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e94 (32.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eReligious and cultural anti-vaccination sentiments.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e176 (60.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e116 (39.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eMistrust of government intentions.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e176 (60.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e116 (39.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eBusy schedules by the stakeholders (health workers, VHTs, and Teachers)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e177 (60.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e115 (39.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eLong waiting times for girls at vaccination centre\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e185 (63.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e107 (36.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003cb\u003eSource: Primary data, 2022\u003c/b\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003e3.7 Knowledge of Human Papilloma Virus\u003c/b\u003e: The completion rate for the two-dose HPV vaccination series was 27.49%. Most respondents (92.1%) had information about HPV, primarily from health workers (33.6%). While 58.2% correctly identified the eligible age (9\u0026ndash;14 years), a significant knowledge gap existed regarding the number of doses, with 53.4% incorrectly believing only one dose was required. Consequently, 51.0% reported their daughters received only one dose.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003e3.8 Attitude Towards HPV Vaccines\u003c/h3\u003e\n\u003cp\u003e64.7% of respondents agreed the HPV vaccine is very expensive, while 79.1% believed it effectively protects against HPV.\u003c/p\u003e\u003cdiv id=\"Sec23\" class=\"Section2\"\u003e\u003ch2\u003e3.9 Bivariate Analysis of Key Variables\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cb\u003eDemographic Characteristics\u003c/b\u003e\u003c/p\u003e\u003cp\u003eDaughter's age had a significant impact, with girls aged 11\u0026ndash;13 twice as likely to have received the vaccine as those aged 8\u0026ndash;10 (COR\u0026thinsp;=\u0026thinsp;2.01; 95% CI: 1.10\u0026ndash;3.67; p\u0026thinsp;=\u0026thinsp;0.023). Employed caregivers showed a borderline significance with higher uptake (COR\u0026thinsp;=\u0026thinsp;2.23; p\u0026thinsp;=\u0026thinsp;0.076). Higher education levels were associated with greater vaccination probabilities, though not statistically significant.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eDistance from Health Center\u003c/h3\u003e\n\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eNo significant correlation was found between distance and HPV vaccine uptake.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003eClass Attended\u003c/h3\u003e\n\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eNo significant correlation was found between school class and HPV vaccine uptake.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003eIndividual Factors\u003c/h3\u003e\n\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eChange of residence (OR\u0026thinsp;=\u0026thinsp;0.50, p\u0026thinsp;=\u0026thinsp;0.001) and school absenteeism (OR\u0026thinsp;=\u0026thinsp;0.73, p\u0026thinsp;=\u0026thinsp;0.037) were significantly linked with lower odds of HPV vaccine completion. Other individual factors were not statistically significant.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003eHealth Facility Factors\u003c/h3\u003e\n\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eLimited knowledge of HPV vaccination schedule by health workers (OR\u0026thinsp;=\u0026thinsp;0.94, p\u0026thinsp;=\u0026thinsp;0.043) and lack of clear government programs targeting out-of-school girls (OR\u0026thinsp;=\u0026thinsp;0.97, p\u0026thinsp;=\u0026thinsp;0.035) were associated with lower risks of poor uptake. Conversely, understaffing (OR\u0026thinsp;=\u0026thinsp;1.967, p\u0026thinsp;=\u0026thinsp;0.006) and vaccine shortages/inadequate cold chain infrastructure (OR\u0026thinsp;=\u0026thinsp;1.748, p\u0026thinsp;=\u0026thinsp;0.004) significantly raised the likelihood of low uptake.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003eCommunity Factors\u003c/h3\u003e\n\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eRumors/misconceptions (OR\u0026thinsp;=\u0026thinsp;1.45, p\u0026thinsp;=\u0026thinsp;0.033), religious/cultural anti-vaccination sentiments (OR\u0026thinsp;=\u0026thinsp;1.59, p\u0026thinsp;=\u0026thinsp;0.031), and mistrust of government intentions (OR\u0026thinsp;=\u0026thinsp;1.80, p\u0026thinsp;=\u0026thinsp;0.009) were significantly linked to low uptake. Long waiting times were surprisingly linked to a decrease in low uptake (OR\u0026thinsp;=\u0026thinsp;0.75, p\u0026thinsp;=\u0026thinsp;0.046).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003eKnowledge Related Factors\u003c/h3\u003e\n\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eHearing about HPV (OR\u0026thinsp;=\u0026thinsp;4.65, p\u0026thinsp;=\u0026thinsp;0.001), knowing the eligible age (OR\u0026thinsp;=\u0026thinsp;2.29, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), believing vaccination is right (OR\u0026thinsp;=\u0026thinsp;3.57, p\u0026thinsp;=\u0026thinsp;0.003), and knowing the correct number of doses (OR\u0026thinsp;=\u0026thinsp;2.20, p\u0026thinsp;=\u0026thinsp;0.005) were significantly associated with higher uptake.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec30\" class=\"Section2\"\u003e\u003ch2\u003e3.10 Multivariable Logistic Regression Analysis\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eMultivariable Logistic Regression Analysis of Factors Associated with low completion rates of the two-dose HPV vaccine in Rukiga District, Uganda.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFactor\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eVariable Option\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003en\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eAOR (95% CI)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDemographic Factors\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCaretaker Relationship: Mother\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e128\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e1.70 (1.05\u0026ndash;2.75)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.030\u003c/b\u003e\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: None\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e0.19 (0.04\u0026ndash;0.87)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.033\u003c/b\u003e\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: Primary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e96\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e0.50 (0.30\u0026ndash;0.83)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.007\u003c/b\u003e\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: Peasant\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e111\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e0.49 (0.28\u0026ndash;0.87)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.013\u003c/b\u003e\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\u003eChange of residence: Yes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e110\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e0.50 (0.37\u0026ndash;0.69)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\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: Yes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e175\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e0.73 (0.59\u0026ndash;0.91)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.037\u003c/b\u003e\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\u003eLimited knowledge by health workers: Yes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e191\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e0.94 (0.70\u0026ndash;1.24)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.043\u003c/b\u003e\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: Yes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e198\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e0.97 (0.73\u0026ndash;1.29)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.035\u003c/b\u003e\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: Yes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e193\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e1.75 (1.04\u0026ndash;2.93)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.004\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUnderstaffing: Yes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e168\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e1.97 (1.05\u0026ndash;3.68)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.006\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCommunity Factors\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRumors / misconceptions: Yes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e198\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e1.45 (1.03\u0026ndash;2.04)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.033\u003c/b\u003e\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: Yes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e176\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e1.59 (1.04\u0026ndash;2.42)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.031\u003c/b\u003e\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: Yes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e176\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e1.80 (1.16\u0026ndash;2.79)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.009\u003c/b\u003e\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: Yes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e185\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e0.75 (0.57\u0026ndash;0.98)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.046\u003c/b\u003e\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: Yes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e269\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e4.65 (1.89\u0026ndash;11.45)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\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 (9\u0026ndash;14 yrs): Correct\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e170\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e2.29 (1.47\u0026ndash;3.56)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\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: Yes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e262\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e3.57 (1.52\u0026ndash;8.41)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.003\u003c/b\u003e\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 (2 doses): Correct\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e74\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e2.20 (1.25\u0026ndash;3.88)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.005\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003eNote. AOR\u0026thinsp;=\u0026thinsp;Adjusted Odds Ratio; CI\u0026thinsp;=\u0026thinsp;Confidence Interval. Bolded values indicate statistically significant associations (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe results of the multivariate logistic regression analysis (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e) identified key factors associated with low HPV vaccine uptake among adolescent girls. Demographically, daughters with mothers as primary caretakers were more likely to miss vaccination (AOR\u0026thinsp;=\u0026thinsp;1.70; p\u0026thinsp;=\u0026thinsp;0.030), while caretakers with no formal education (AOR\u0026thinsp;=\u0026thinsp;0.19; p\u0026thinsp;=\u0026thinsp;0.033) or only primary education (AOR\u0026thinsp;=\u0026thinsp;0.50; p\u0026thinsp;=\u0026thinsp;0.007) and those in peasant occupations (AOR\u0026thinsp;=\u0026thinsp;0.49; p\u0026thinsp;=\u0026thinsp;0.013) were less likely to have daughter\u0026rsquo;s complete vaccination.\u003c/p\u003e\u003cp\u003eAt the individual level, girls who changed residence (AOR\u0026thinsp;=\u0026thinsp;0.50; p\u0026thinsp;=\u0026thinsp;0.001) or experienced absenteeism/dropout (AOR\u0026thinsp;=\u0026thinsp;0.73; p\u0026thinsp;=\u0026thinsp;0.037) had lower uptake. Health system constraints, including vaccine shortages/cold chain issues (AOR\u0026thinsp;=\u0026thinsp;1.75; p\u0026thinsp;=\u0026thinsp;0.004) and understaffing (AOR\u0026thinsp;=\u0026thinsp;1.97; p\u0026thinsp;=\u0026thinsp;0.006), also significantly affected completion.\u003c/p\u003e\u003cp\u003eCommunity-level barriers, notably rumors/misconceptions (AOR\u0026thinsp;=\u0026thinsp;1.45; p\u0026thinsp;=\u0026thinsp;0.033), religious/cultural opposition (AOR\u0026thinsp;=\u0026thinsp;1.59; p\u0026thinsp;=\u0026thinsp;0.031), and mistrust of government (AOR\u0026thinsp;=\u0026thinsp;1.80; p\u0026thinsp;=\u0026thinsp;0.009), were associated with low uptake. Conversely, caregiver knowledge strongly facilitated vaccination: awareness of HPV (AOR\u0026thinsp;=\u0026thinsp;4.65; p\u0026thinsp;=\u0026thinsp;0.001), correct eligible age (AOR\u0026thinsp;=\u0026thinsp;2.29; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), belief in vaccination (AOR\u0026thinsp;=\u0026thinsp;3.57; p\u0026thinsp;=\u0026thinsp;0.003), and knowledge of the two-dose schedule (AOR\u0026thinsp;=\u0026thinsp;2.20; p\u0026thinsp;=\u0026thinsp;0.005) significantly improved completion.\u003c/p\u003e\u003cp\u003e These findings indicate that low HPV vaccine uptake in Rukiga District is influenced by a combination of caregiver characteristics, individual behaviors, health system limitations, community perceptions, and knowledge gaps, emphasizing the need for integrated interventions targeting both awareness and service delivery.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec31\" class=\"Section2\"\u003e\u003ch2\u003e3.11 Qualitative Data Analysis (Thematic Presentation):\u003c/h2\u003e\u003cp\u003e\u003cstrong\u003eIndividual-Level Barriers\u003c/strong\u003e\u003cp\u003eIncluded lack of awareness about vaccination eligibility and purpose, school absenteeism (due to fees, household responsibilities, early menstruation, farm work), frequent family relocation and school transfers disrupting follow-ups, physical barriers (poor road networks), fear of injection pain, and negative influence from caregivers or peers (misconceptions, adverse effect stories).\u003c/p\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eHealth Facility Barriers\u003c/h3\u003e\n\u003cp\u003e Included limited knowledge among healthcare workers, VHTs, and teachers about HPV vaccination guidelines, cold chain and logistical challenges (shortages of ice packs, lack of refrigeration), inadequate community engagement and mobilization (seasonal activities preventing access to information), transportation challenges (unreliable transport, canceled sessions), expectations of monetary incentives (demotivation of staff), staff shortages, and unfriendly behavior from healthcare workers.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eCommunity Level Barriers\u003c/strong\u003e\u003cp\u003eIncluded rumors and misconceptions (vaccine promoting early sexual activity, infertility concerns, HIV content), traditional and religious beliefs (vaccination contradicting cultural/religious norms) and lack of successful sensitization campaigns leading to community skepticism.\u003c/p\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe low HPV vaccine series uptake in adolescent girls in Rukiga District is a complex issue driven by a combination of demographic, individual, health system, and community factors, consistent with the Health Belief Model (HBM) [15]\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.1 Caregiver Relationship and Gender\u003c/strong\u003e: Maternal involvement significantly boosts HPV vaccine uptake in adolescent girls aligning with HBM's cues to action and self-efficacy constructs. This finding is consistent with prior research emphasizing maternal influence [26, 27]. However, socioeconomic factors can moderate this influence as seen in lower HPV vaccination uptake among girls with single mothers in other regions. This suggests a need for targeted interventions that empower mothers through education and address structural barriers in vulnerable households.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.2 Caregiver Education and Occupation\u003c/strong\u003e: Higher caregiver education is strongly linked to increased HPV vaccination uptake in adolescent girls as educated caregivers are better equipped to understand health information and vaccination benefits, reflecting reduced perceived barriers and increased self-efficacy in the HBM [15, 26]. Occupation also plays a role, with peasant farmers having lower uptake of HPV vaccination in adolescent girls likely due to economic constraints and lower health literacy reinforcing perceived obstacles [28]. These findings underscore the need for accessible, culturally appropriate health education and flexible vaccination hours for low-literacy and working populations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.3 Class Grade Absenteeism and Change of Residence\u003c/strong\u003e: School-based programs are effective, with Primary Four girls showing the highest HPV vaccination uptake in adolescent girls [29]. However, absenteeism, school dropout and residential mobility significantly hinder completion of the vaccine series by disrupting exposure to vaccination cues and undermining confidence in multi-dose regimens [30]. This highlights a need for flexible vaccination strategies, catch-up clinics, and interoperable digital health records to track mobile populations and ensure continuity of care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.4 Distance and Transport\u003c/strong\u003e: Surprisingly, distance from health facilities was not a significant barrier suggesting the effectiveness of school-based and community outreach programs in bridging geographic gaps in low HPV vaccination uptake in adolescent girls [15, 31]. However, qualitative data indicated that poor infrastructure can still pose challenges emphasizing the importance of sustained investment in decentralized outreach efforts [32].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.5 Health Facility Factors: Logistics, Staffing, and Waiting Times\u003c/strong\u003e: Logistical issues, such as vaccine stockouts and inadequate cold chain infrastructure, significantly impede vaccine uptake in adolescent girls by frustrating caregivers and eroding trust. Understaffing further exacerbates these issues by disrupting service delivery [15, 16, 28]. These systemic weaknesses increase perceived barriers and undermine cues to action within the HBM. Efforts to strengthen supply chain management, invest in infrastructure and prioritize recruitment and retention of healthcare workers are critical. While long waiting times were unexpectedly associated with lower missed HPV vaccinations in adolescent girls suggesting high caregiver motivation, improving clinic workflow remains important [15].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.6 Community Trust and Cultural Opposition\u003c/strong\u003e: Mistrust in government and health systems, fueled by misinformation and conspiracy theories, significantly contributes to low HPV vaccine uptake in adolescent girls [33]. Religious and cultural resistance also acts as a barrier by diminishing perceived benefits and increasing perceived threat [15, 34]. Conversely, engaging trusted religious leaders can significantly improve HPV vaccine acceptance by serving as powerful cues to action. Transparent, culturally sensitive communication strategies are essential to rebuild trust and combat misinformation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.7 Knowledge, Attitudes and Misinformation\u003c/strong\u003e: Parental knowledge of HPV and vaccination benefits is a powerful predictor of uptake, increasing perceived benefits, reducing barriers, and boosting self-efficacy [35\u0026ndash;38]. Misinformation, including fear of injection pain and peer influence, reduces confidence and creates perceived barriers to low uptake of HPV vaccination in adolescent girls [15, 34, 39]. This highlights the need for structured community education, myth-busting campaigns, and school-based sensitization to foster positive vaccine attitudes and effectively translate awareness into action [40].\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eLow HPV vaccine series completion in Rukiga District is primarily driven by caregiver knowledge gaps, socioeconomic disparities, and systemic limitations in health service delivery. Community mistrust and misinformation exacerbate these challenges. Addressing these complex issues requires integrated interventions that target both demand-side (e.g., education, trust-building) and supply-side (e.g., infrastructure, staffing) barriers. Prioritizing these strategies will significantly contribute to reducing the burden of HPV-related diseases and protecting adolescent health in Uganda.\u003c/p\u003e"},{"header":"Recommendations","content":"\u003cp\u003eImproving HPV vaccination uptake requires a comprehensive strategy that begins with targeted training for healthcare workers and Village Health Teams (VHTs) on delivering culturally sensitive campaigns. These efforts should be supported by simplified, low-literacy materials and active follow-up in schools and communities. Medium-term priorities include implementing an age-based policy, strengthening cold chain and tracking systems, and aligning vaccination schedules with local calendars. Engaging religious and community leaders is crucial for building trust and ensuring success. Assigning clear roles to the Ministry of Health, healthcare workers, schools and VHTs, along with using multiple reminder methods, will strengthen collaboration and community trust. Continuous monitoring and adaptation of these strategies will be key to sustaining high vaccination coverage over time.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAOR Adjusted Odds Ratio\u003c/p\u003e\u003cp\u003eCOR Crude Odds Ratio\u003c/p\u003e\u003cp\u003eEPI Expanded Programme on Immunization and vaccination\u003c/p\u003e\u003cp\u003eHBM Health Belief Model\u003c/p\u003e\u003cp\u003eHPV Human Papilloma Virus\u003c/p\u003e\u003cp\u003eMUST Mbarara University of Science and Technology\u003c/p\u003e\u003cp\u003eUNCST Uganda National Council for Science and Technology\u003c/p\u003e\u003cp\u003eOR Odds Ratio\u003c/p\u003e\u003cp\u003e REC Research Ethics Committee\u003c/p\u003e\u003cp\u003eSPSS Statistical Package for the Social Sciences\u003c/p\u003e\u003cp\u003eVHT Village Health Team\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003cstrong\u003e:\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\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe express our gratitude to the community of Rukiga 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\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo external funding was received for this work\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors and Affiliations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMbonigaba Rukarama Evarist and Ronald Arineitwe Kibonire, Department of community Health, School of medicine Kable university, Kabale District, Kampala city, Uganda\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eContributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMbonigaba Rukarama Evarist (MRE) conceptualized the study, designed the study framework, led data collection and interpretation, prepared the manuscript and the paper. He is the principal investigator. Ronald Arineitwe Kibonire (RAK) as co-author provided guidance throughout the study's conception, design, data collection, analysis phases, participated in paper writing, reviewed the manuscript and offered valuable feedback for refinement. He served as the co-author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCorresponding author\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCorrespondence to Mbonigaba Rukarama Evarist.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the Declaration of Helsinki and all applicable ethical guidelines for research involving human participants. Clearance to conduct this study was obtained from the Department of community of Kabale University 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\u003eInformed consent was obtained from all participants. Care was taken to ensure the anonymity of participants as no names or otherwise identifying information were included in the data. Efforts were also made to prevent either physical or psychological harm or distress to the participants during and after interviewing them.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors hereby declare that they have no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eReza S, Anjum R, Khandoker RZ, Khan SR, Islam MR, Dewan SMR. Public health concern-driven insights and response of low-and middle-income nations to the World health Organization call for cervical cancer risk eradication. Gynecologic Oncol Rep. 2024;54:101460.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRayner M, Welp A, Stoler MH, Cantrell LA. Cervical cancer screening recommendations: now and for the future. Healthcare. Volume 11. MDPI; 2023, August. p. 2273. 16.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSu P, Ma J, Yu L, Tang S, Sun P. 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Sociodemographic determinants of HPV vaccine awareness, uptake, and intention among parents of adolescents in France 2021-22. Hum vaccines immunotherapeutics. 2024;20(1):2381300.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHolroyd TA, Yan SD, Srivastava V, Srivastava A, Wahl B, Morgan C, Jennings MC. Designing a pro-equity HPV vaccine delivery program for girls who have dropped out of school: community perspectives from uttar pradesh, India. Health Promot Pract. 2022;23(6):1039\u0026ndash;49.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKaranja-Chege CM. HPV vaccination in Kenya: the challenges faced and strategies to increase uptake. Front Public Health. 2022;10:802947.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEgbon M, Ojo T, Aliyu A, Bagudu ZS. Challenges and lessons from a school-based human papillomavirus (HPV) vaccination program for adolescent girls in a rural Nigerian community. 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(2024). \u0026lsquo;Addressing HPV vaccine hesitancy: unveiling concerns and building trust\u0026rsquo;perspectives of adolescent girls and parents in Kisumu County, Kenya. ecancermedicalscience, 18, 1735..\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMotilal, S., Mohepath, N., Moncur, J., Mohess, R., Mohan, V., Mohammed, S., \u0026hellip; Mohess,R. A. (2023). Parental knowledge, attitudes, and perceptions impacting willingness to vaccinate against the human papillomavirus in Trinidad. Cureus, 15(8)..\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAkoro U, Stuart G, Stuart GP. (2024). Knowledge, Attitudes, and Perceptions of African Parents in New Zealand Towards the Human Papillomavirus Vaccine. Cureus, \u003cem\u003e16\u003c/em\u003e(12).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNaoum P, Athanasakis K, Zavras D, Kyriopoulos J, Pavi E. Knowledge, Perceptions and attitudes toward HPV vaccination: a survey on parents of girls aged 11\u0026ndash;18 years old in Greece. Front Global Women's Health. 2022;3:871090.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSmolarczyk K, Duszewska A, Drozd S, Majewski S. Parents\u0026rsquo; knowledge and attitude towards HPV and HPV vaccination in Poland. \u003cem\u003eVaccines\u003c/em\u003e 10, no. 2 (2022): 228.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMilondzo T, Meyer JC, Dochez C, Burnett RJ. Misinformation drives low human papillomavirus vaccination coverage in South African girls attending private schools. Front Public Health. 2021;9:598625.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBitariho GK, Tuhebwe D, Tigaiza A, Nalugya A, Ssekamatte T, Kiwanuka SN. Knowledge, perceptions and uptake of human papilloma virus vaccine among adolescent girls in Kampala, Uganda; a mixed-methods school-based study. BMC Pediatr. 2023;23(1):368.\u003c/span\u003e\u003c/li\u003e\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-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"HPV vaccination, low uptake, adolescent girls, Rukiga District, Uganda, caregivers, health system barriers, community factors, knowledge, attitudes","lastPublishedDoi":"10.21203/rs.3.rs-7394339/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7394339/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study investigated the low completion rates of the HPV vaccine series in Rukiga District, Uganda, a critical step for cervical cancer prevention.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA mixed-methods, cross-sectional study was conducted which included a final sample of 292 parents or caregivers of adolescent girls. Researchers used multivariate logistic regression to identify determinants of completing the two-dose regimen and conducted in-depth interviews with 11 health workers involved in immunisationand 10 Village Health Team members to explore barriers.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOnly 27.49% of eligible girls completed the two-dose series. Girls with mothers as caregivers had greater odds of completion (AOR = 1.70, 95% CI: 1.05-2.74, p = 0.030). Caregivers without formal education were less likely to vaccinate their daughters (AOR = 0.19, 95% CI: 0.05-0.74, p = 0.033). Awareness of HPV infection was a powerful predictor of uptake (AOR = 4.65, 95% CI: 2.03-10.66, p \u0026lt; 0.001). Qualitative data highlighted barriers including vaccine safety misinformation, insufficient health worker training, stockouts, long wait times, and community distrust.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe low HPV vaccine completion rate is attributed to a combination of caregiver knowledge gaps, socioeconomic obstacles, and systemic health service limitations. Community mistrust and misinformation further exacerbate the issue. Interventions should be integrated to address both supply and demand-side barriers, increase health worker capacity, and rebuild community trust.\u003c/p\u003e","manuscriptTitle":"Factors Associated with Low Uptake of Human Papilloma Virus (HPV) Vaccination Series in Adolescent Girls in Rukiga District, Uganda","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-22 05:52:39","doi":"10.21203/rs.3.rs-7394339/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-08-21T08:23:33+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-21T01:12:23+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-21T01:11:26+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-08-17T20:41:12+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","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":"August 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-10-06T11:08:30+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-22 05:52:39","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7394339","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7394339","identity":"rs-7394339","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}