Bridging the Service Gap – Health Facility Challenges in HPV Vaccine Uptake in Rural Uganda

Bridging the Service Gap – Health Facility Challenges in HPV Vaccine Uptake in Rural 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 Bridging the Service Gap – Health Facility Challenges in HPV Vaccine Uptake in Rural Uganda Mbonigaba Rukarama Evarist, Ronald Arineitwe Kibonire This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7597029/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 13 You are reading this latest preprint version Abstract Background: Cervical cancer, largely preventable through HPV vaccination, remains a significant public health burden in Uganda. Despite national immunization efforts, low completion rates for the two-dose HPV vaccine series persist, particularly in rural districts like Rukiga. This study aimed to investigate health facility-related factors contributing to the low uptake of the HPV vaccination series among adolescent girls in Rukiga District, Uganda. Methods: A cross-sectional study employing mixed methodologies was conducted with 292 adolescent girls and their caregivers in Rukiga District between September and November Multivariate logistic regression was utilized to identify health facility-level determinants of completing the two-dose HPV vaccine regimen. Additionally, qualitative data were gathered through in-depth interviews with 12 health workers and 10 Village Health Team members to explore operational and service delivery barriers to vaccine uptake. Results: The study found that only 27.49% of eligible girls completed the two-dose HPV vaccination series. Significant health facility-related barriers included vaccine shortages and inadequate cold chain infrastructure (AOR = 1.75, 95% CI: 1.04-2.93, p = 0.004) and understaffing of healthcare workers (AOR = 1.97, 95% CI: 1.05-3.68, p = 0.006). Limited knowledge among health workers regarding the HPV vaccination schedule (AOR = 0.94, 95% CI: 0.70-1.24, p = 0.043) and the lack of clear government programs targeting out-of-school girls (AOR = 0.97, 95% CI: 0.73-1.29, p = 0.035) also contributed to reduced uptake. Qualitative findings further highlighted issues such as poor records management, inadequate community engagement by facilities, transportation challenges for vaccine delivery, and low staff motivation due to lack of incentives. Conclusion: Health facility limitations, particularly concerning vaccine supply, human resources, and operational efficiency, are critical impediments to completing the HPV vaccine series in Rukiga District. Addressing these systemic weaknesses through investments in cold chain infrastructure, increased staffing, enhanced health worker training, and robust outreach strategies is essential to improve vaccine coverage and reduce the burden of cervical cancer. HPV vaccination low uptake health facility factors health system barriers vaccine supply cold chain understaffing health worker knowledge rural health Uganda 1. Introduction/Background Cervical cancer is a major global health issue, especially in low- and middle-income nations where 90% of deaths occur [ 1 , 2 ]. It is the fourth most frequent cancer in women worldwide and the most common gynaecological malignancy with Human Papillomavirus (HPV) being the most common cause [ 3 , 4 , 5 , 6 ]. High-risk HPV forms 16 and 18 are linked to nearly 70% of cervical cancer occurrences [ 3 , 4 ]. In Uganda, cervical cancer is the leading cause of cancer-related death in women, accounting for nearly 40% of all female cancer cases [ 7 , 8 ]. Uganda's age-standardized cervical cancer incidence and mortality rates are 56.7 and 40.1 per 100,000 women, respectively, which are four to five times higher than global standards [ 9 , 10 , 11 ]. Uganda initiated its first HPV vaccine demonstration program in 2006, assessing both school-based and age-based community delivery strategies [ 12 ]. The HPV vaccination was officially included in the nationwide routine immunization program in 2015 [ 13 ]. 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 [ 14 , 15 ]. This can be linked to inadequate follow-up mechanisms, poor record management, vaccine stockouts, low health worker motivation, misinformation, and insufficient community engagement. In Rukiga District, HPV1 adoption has remained quite high thanks to school-based outreach but the second dose absorption has fallen dramatically with recent data indicating a dropout rate of 23.49 percent [ 16 ]. This is especially concerning because complete protection against HPV and prevention of cervical cancer requires completion of the two-dose regimen in adolescent females aged 9 to 14 years [ 15 ]. Health facilities play a pivotal role in the successful implementation and sustainment of vaccination programs. Operational inefficiencies, logistical challenges, and human resource limitations within health facilities can significantly impede vaccine delivery and uptake. Understanding these specific health facility-related barriers in rural settings like Rukiga is essential to inform targeted initiatives that strengthen the supply side of HPV vaccination. This study aims to identify and analyze these health facility factors to guide improvements in service delivery and ultimately increase HPV vaccine series completion. 2. 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 [17,18.19]. The cross-sectional design was chosen for its efficiency in assessing relationships between variables at a single point in time, providing a snapshot of the factors influencing HPV vaccine uptake. 2.2 Study Setting. The study was conducted in Rukiga District in southwestern Uganda, which borders Ntungamo District, the Republic of Rwanda, Kabale District, Rubanda District, and Rukungiri District. It has a total land area of 426.3 km2 and a total population of 132,355 people by sex, with 29,495 total households and a population density of 268/km2 [ 20 ]. The district was purposefully chosen due to its HPV vaccination program implementation, rural setting, limited access to health facilities, and integration into Uganda's Expanded Program for Immunization. Two sub-counties were selected because of their lower vaccination rates and accessibility issues. 2.3 Study Population and Sampling. Quantitative Study The quantitative population included parents and guardians of adolescent girls aged 9–14 years eligible to receive the HPV vaccine. They were chosen because they are ultimately in charge of making decisions about whether or not to accept or refuse the vaccine among their children. Minors (under 18) were excluded as primary respondents since vaccination would have to be given at school hours when they would be away from their parents or other caregivers [ 21 , 22 ]. Qualitative Study Key informants for the qualitative part of this study consisted of health workers and Village Health Team (VHT) members [ 23 ]. Health workers directly implement vaccination service delivery, while VHTs represent the immediate linkage of the health system to the population, providing health education and addressing myths and misconceptions. 2.3.1 Sampling Technique/Method. A multistage sampling approach was used. Two sub-counties characterized by lower HPV vaccination rates and accessibility challenges were purposively selected. Parishes within these sub-counties were chosen through simple random sampling, and villages were then randomly selected. Households with adolescent girls aged 9 to 14 years, based on Village Health Team records, were selected proportionally to village size, followed by systematic random sampling, resulting in a final sample of 292 parents or caregivers. For qualitative data, 11 health workers involved in EPI and HPV vaccination, and 10 VHT members from the selected villages, were purposively sampled. 2.3.2 Sample Size and Determination. The sample size for the quantitative study was calculated using Cochrane’s equation, assuming a 95% confidence level and a P value of 0.05. n0​=Z 2 pq​/ e 2 Where: n0​ = required sample size Z = Z-score (1.96 for 95% CI) p = estimated proportion (0.5 for maximum variability) e = Desired level of precision (0.05) q = 1 − p This yielded n0​=385. For a finite population (N = 1200 households), the Cochran sample size correction was applied: n = 1 + N(n0​−1) /​n0​​ Substituting the values: n = 1 + 1200(385 − 1) ​/385​=1 + 1200(384) ​/385​=1 + 0.32/385​=1.32/385​=291.666667 = 292 Thus, 292 partipants were included in the study as the adjusted sample size. 2.3.3 Inclusion and Exclusion Criteria. Inclusion Parents or primary caregivers of adolescent girls aged 9–14 years found at home from selected sub-counties in Rukiga District who provided informed consent. Exclusion Households where caregivers had significant cognitive or hearing impairments, and child-headed households, due to challenges in obtaining reliable responses. 2.4 Study Variables. Dependent variable Low uptake of HPV vaccination series. Independent variables : Health facility barriers: Poor documentation, limited service providers' knowledge, lack of strategies targeting out-of-school girls, shortages of vaccine supplies, limited social mobilization, unreliable transportation, lack of staff motivation, and shortage of healthcare workers. 2.5 Data Collection Methods. A mixed-methods approach was used, combining semi-structured interviewer-administered questionnaires for quantitative data and Key Informant Interviews (KIIs) for qualitative data. Ten trained research assistants conducted household visits, and the semi-structured design allowed for standardized responses and in-depth insights. 2.5.1 Development of Interview Guides. The questionnaire and Key interview guides were developed specifically for this study, drawing from a comprehensive review of existing literature on HPV vaccine uptake and adapting relevant items from tools used in similar studies to enhance content validity. These instruments were designed by the principal investigator, translated into the predominant local language spoken in the study area, and subsequently back-translated into English to ensure linguistic and conceptual accuracy [ 37 ]. These tools were newly developed for this research and have not been previously published elsewhere. 2.5.2 Pre-testing Tools. Tools were piloted in Kashaki Village, an external site, with 40 parents/caretakers and in-depth interviews with three health workers and two VHT members. Pre-testing ensured clarity, cultural appropriateness, and allowed for revisions and standardization of the tools. Interviews were conducted in Rukiga or Runyankole for parents/caretakers, and English for health workers. 2.5.3 Recruitment and Training of Research Assistants. Ten research assistants with good knowledge of English and Rukiga-Runyankole, medical backgrounds, and interview experience were recruited and trained. They were supervised daily to ensure accuracy and completeness of data collection. 2.5.4 Data Collection Tools and Field Editing. Data was collected using pre-tested semi-structured questionnaires and checklists. Field editing was performed daily to ensure accuracy, completeness, and address non-responses. 2.6 Validity and Reliability of the Research Instrument:2.6.1 Quantitative Data. Validity : Content validity was ensured through expert consultations and literature review, and construct validity was assessed through pilot testing. Face validity was ensured by involving VHT members in reviewing the instrument for clarity, cultural appropriateness and relevance. Reliability : Confirmed through Cronbach’s alpha (0.72 to 0.83) indicating good internal consistency, and test-retest reliability (0.82) showing strong stability over time [ 24 ]. 2.6.2 Qualitative Data. Validity : Member checking was employed by presenting preliminary results to selected participants to confirm accuracy of interpretations. Reliability : Intercoder reliability was applied, with multiple researchers independently coding transcripts and resolving discrepancies through consensus. 2.7 Data Quality Control. Quality control was ensured through adequate questionnaires, proper identification of key informants, training of research assistants, daily supervision, review, and entry of data. 2.8 Data Management and Analysis. Quantitative Data Analysis Data was checked for completeness and accuracy, entered into Epi-Info, and then transferred to SPSS for analysis. Univariate analysis generated frequency tables and descriptive parameters. Bivariate analysis compared the dependent variable with independent variables using confidence intervals and p-values. Multivariable logistic regression analysis adjusted for confounding and determined factors associated with HPV vaccine uptake, including all variables from bivariate analysis regardless of their initial p-values, to account for potential confounders or clinically/theoretically significant variables. Qualitative Data Analysis. Open-ended responses were systematically coded by allocating them to frequent themes, allowing structured interpretation and identification of trends and patterns between participant responses. 2.9 Ethical Consideration. Approval was obtained from Kabale University and Mbarara University Research Ethics Committee. Permission was also sought from the Rukiga District Health Officer. Respondents were informed about the study objectives and process, and informed consent was obtained, with participation being voluntary and confidentiality maintained. 3. Results The study involved 292 respondents and the overall completion rate for the two-dose HPV vaccination series in Rukiga District was 27.49% [ 16 ]. 3.1 Health Factors Associated with Low Uptake: Quantitative Findings (Table 5) 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 From table above, sseveral health system challenges were identified as contributing factors to low HPV vaccine uptake. These included poor records management by health workers (66.4%), limited knowledge of the HPV vaccination schedule among health workers (65.4%), and the absence of clear government programs specifically targeting out-of-school girls (66.1%). Vaccine shortages and inadequate cold chain infrastructure were also cited by 66.1% of respondents as obstacles. Additionally, untimely transportation of staff and vaccines was seen as a significant issue by 73.3%, leading to community uncertainty. Lack of staff motivation, such as the absence of outreach allowances, was indicated by 73.6% as a barrier to immunization completion, while understaffing within healthcare facilities was believed by 57.5% to limit the implementation of HPV vaccination programs. Bivariate Analysis (Table 1) : Health factors Value option OR P -Value Poor records management by health workers Yes 194 0.951 0.109 No 98 1.112 Limited knowledge of HPV vaccination schedule by the health workers Yes 191 0.94 0.043 No 101 1.15 Lack of clear programs by the government which target girls out of school. Yes 198 0.97 0.035 No 94 1.06 Shortage of vaccines and inadequate cold chain infrastructure for storing HPV vaccines. Yes 193 1.748 0.004 No 99 0.519 Untimely transportation of staff and vaccines Yes 214 0.931 0.574 No 78 1.248 Lack of staff motivation Yes 125 1.063 0.645 No 77 0.855 Understaffing of healthcare workers Yes 168 1.967 0.006 No 124 0.577 Source : Primary data, 2022 From table one above, key health system barriers to HPV vaccine uptake include limited health worker knowledge (OR = 0.94, p = 0.043) and lack of government programs for out-of-school girls (OR = 0.97, p = 0.035), both significantly lowering uptake. Vaccine shortages and cold chain issues (OR = 1.75, p = 0.004) and understaffing (OR = 1.97, p = 0.006) significantly increased the risk of low vaccination rates. Other factors like poor records management and transportation delays were noted but not statistically significant. Multivariable Logistic Regression Analysis (Table 2) Factor Category Variable Variable Option n OR (95% CI) P-value Demographic Factors Age of Caretaker 20–30 35 0.65 (0.32–1.31) 0.220 31–40 107 0.94 (0.56–1.58) 0.820 41–50 125 1.42 (0.85–2.36) 0.180 50+ (Ref) 12 1.00 – Gender of Caretaker Female 149 2.18 (0.85–5.57) 0.096 Male (Ref) 7 1.00 – Caretaker Relationship Mother 128 1.70 (1.05–2.75) 0.030 Others (Ref) 28 1.00 – Education Level None 2 0.19 (0.04–0.87) 0.033 Primary 96 0.50 (0.30–0.83) 0.007 Secondary+ (Ref) 61 1.00 – Occupation Peasant 111 0.49 (0.28–0.87) 0.013 Employed/Business (Ref) 31 1.00 – Marital Status Married 134 1.43 (0.73–2.80) 0.280 Not Married (Ref) 22 1.00 – Distance to Health Center Distance to Health Center < 1 km 1 Not estimable – 1–3 km (Ref) 110 1.00 – 4–6 km 31 0.96 (0.53–1.74) 0.892 ≥ 6 km 13 1.03 (0.43–2.44) 0.947 Not aware 1 0.87 (0.05–15.4) 0.921 Class Level P2 3 0.89 0.17–4.54 0.87 P3 61 0.95 0.51–1.78 0.83 P4 (Reference) 107 1.00 (Ref) – 1.00 P5 62 0.93 0.49–1.75 0.78 P6 34 1.05 0.49–2.25 0.87 P7 25 1.12 0.48–2.61 0.74 Individual Factors Inadequate knowledge about HPV Yes 207 1.28 (0.89–1.84) 0.114 No 85 0.64 – Change of residence Yes 110 0.50 (0.37–0.69) 0.001 No 182 2.14 – Absenteeism / dropout Yes 175 0.73 (0.59–0.91) 0.037 No 117 2.27 – Caregiver discouragement Yes 182 0.85 (0.69–1.05) 0.222 No 110 1.69 – Poor road infrastructure Yes 209 1.39 (0.92–2.10) 0.108 No 83 0.72 – Fear of injection Yes 201 1.21 (0.83–1.77) 0.311 No 91 0.82 – Peer/Caregiver discouragement Yes 197 1.17 (0.79–1.72) 0.420 No 95 0.85 – Health System Factors Poor records management Yes 194 0.95 (0.72–1.26) 0.109 No 98 1.11 – Limited knowledge by health workers Yes 191 0.94 (0.70–1.24) 0.043 No 101 1.15 – No gov’t program for out of school girls Yes 198 0.97 (0.73–1.29) 0.035 No 94 1.06 – Shortage/cold chain issues Yes 193 1.75 (1.04–2.93) 0.004 No 99 0.52 – Untimely transport Yes 214 0.93 (0.74–1.17) 0.574 No 78 1.25 – Low staff motivation Yes 125 1.06 (0.80–1.41) 0.645 No 77 0.86 – Understaffing Yes 168 1.97 (1.05–3.68) 0.006 No 124 0.58 – Community Factors Rumors / misconceptions Yes 198 1.45 0.033 No 94 0.58 – Religious/cultural opposition Yes 176 1.59 0.031 No 116 0.62 – Mistrust of government Yes 176 1.80 0.009 No 116 0.58 – Busy stakeholder schedules Yes 177 1.29 0.190 No 115 0.73 – Long waiting time Yes 185 0.75 0.046 No 107 2.20 – Knowledge Factors Heard about HPV Yes 269 4.65 (1.89–11.45) 0.001 No 23 1.00 – Knowledge of eligible age Correct (9–14 yrs) 170 2.29 (1.47–3.56) < 0.001 Belief that vaccination is right Yes 262 3.57 (1.52–8.41) 0.003 Knowledge of correct doses Correct (2 doses) 74 2.20 (1.25–3.88) 0.005 Number of doses received One dose 149 1.20 (0.80–1.80) 0.370 Two doses (Ref) 98 1.00 – Don’t know 45 0.62 (0.35–1.12) 0.110 Source : Primary data, 2022 From Table 2 above, sseveral health system factors significantly influence HPV vaccine uptake. Limited knowledge of the vaccination schedule among health workers was associated with lower uptake (OR = 0.94, p = 0.043), as was the absence of government programs targeting out-of-school girls (OR = 0.97, p = 0.035). Vaccine shortages and inadequate cold chain infrastructure increased the likelihood of low vaccination rates (OR = 1.75, p = 0.004), as did understaffing in healthcare facilities (OR = 1.97, p = 0.006). Although issues like poor records management and transportation delays were commonly reported, they were not statistically significant predictors of vaccine uptake in the analysis. 3.2 Qualitative Data Analysis (Thematic Presentation, Table 3) Theme Subtheme Categories Individual-Level Barriers Lack of Awareness Among Caregivers - Uncertainty about vaccination eligibility (e.g., belief that only girls below 10 qualify). - Limited knowledge about the HPV vaccine. Absenteeism and School Dropout - School absence due to unpaid fees, household responsibilities, or early menstruation. - Some parents keep children home for farm work. Relocation and School Transfers - Families frequently relocate, disrupting vaccine follow-ups. - Parents are often uninformed about vaccination continuity Physical Barriers - Hard-to-reach areas with poor road networks limit vaccine access. Fear of Injection Pain -Adolescents hesitate to complete the HPV vaccination Negative Influence from Caregivers or Peers -Care givers hold misconceptions. -Peers sharing stories of adverse effects or express skepticism Health facility barriers Limited Knowledge Among Healthcare Workers, VHTs, and Teachers - Unclear understanding of HPV vaccination guidelines. Cold Chain and Logistical Challenges - Shortages of ice packs limit the number of doses transported. - Some facilities lack refrigeration for proper vaccine storage. Inadequate Community Engagement and Mobilization - Shortages of ice packs limit the number of doses transported. - Some facilities lack refrigeration for proper vaccine storage Inadequate Community Engagement and Mobilization - Seasonal activities prevent girls from accessing vaccine information. - Many families remain unaware of vaccination campaigns. Transportation Challenges - Lack of reliable transport disrupts vaccine delivery. - Canceled or delayed vaccination sessions cause frustration. Expectations of Monetary Incentives - Healthcare workers and teachers are demotivated by inadequate allowances Staff Shortages - Limited personnel available for vaccination services. Unfriendly Behavior from Healthcare Workers - Some healthcare workers exhibit rude or discouraging attitudes. Community Level Barriers Rumors and Misconceptions Beliefs that the vaccine promotes early sexual activity. - Concerns about infertility and reproductive health risks. Traditional and Religious Beliefs - Perceptions that vaccination contradicts cultural or religious norms. - Some believe being vaccinated violates traditional rules. In the table 3 above, the qualitative interviews with health workers and VHTs revealed several barriers within health facilities that hinder HPV vaccine uptake. Many healthcare providers, VHTs, and teachers lacked updated knowledge about HPV vaccination guidelines, which weakened community mobilization and caregiver education. Persistent vaccine stockouts and inadequate cold chain infrastructure led to missed opportunities. Community engagement was insufficient, with many households unaware of vaccination schedules, especially during busy farming seasons. Transportation challenges, including unreliable vehicles and poor road conditions, disrupted vaccine delivery. Low staff motivation due to inadequate incentives, staff shortages causing delays, and unfriendly behavior from some healthcare workers further discouraged vaccine uptake. 4. Discussion Health facility factors emerged as critical impediments to HPV vaccine uptake in Rukiga District, directly affecting service accessibility, quality, and community trust, consistent with the Health Belief Model (HBM) [14, 25]. 4.1 Vaccine Logistics and Cold Chain Management: The quantitative finding that vaccine shortages and inadequate cold chain infrastructure significantly increased the odds of low uptake of HPV vaccine in adolescent girls (AOR = 1.75, p = 0.004) was strongly supported by qualitative data [25, 26, 17]. Caregivers expressed frustration and loss of trust when vaccines were unavailable after long travel or when health workers lacked supplies, increasing perceived barriers and undermining cues to action and self-efficacy. These findings align with [14, 25, 28] who similarly highlight logistical issues as major barriers to vaccine delivery. Strengthening supply chain management, investing in robust cold chain infrastructure, and ensuring consistent vaccine availability are paramount to building trust and improving consistent access. 4.2 Human Resources and Staffing: Understaffing of healthcare workers nearly doubled the odds of missed vaccinations (AOR = 1.97, p = 0.006). Qualitative insights revealed how staffing shortages disrupt outreach activities, lead to long waiting times, and limit caregivers’ access to services, thereby increasing perceived barriers and weakening cues to action. This is consistent with findings by [14,25]. While [29] suggest misinformation might be more relevant in resource-rich areas, in contexts like Rukiga where access is constrained, staffing is a key operational priority. Policymakers must prioritize the recruitment, training, and retention of healthcare workers, particularly in underserved areas, to enhance service capacity and reduce delays. 4.3 Health Worker Knowledge and Motivation: Limited knowledge among health personnel regarding the HPV vaccination schedule was a significant obstacle (AOR=0.94, p=0.043) [30]. Qualitative data indicated that some health workers, VHTs, and teachers lacked updated knowledge, diminishing their ability to effectively mobilize communities and educate caregivers [30, 31]. This weakens the cues to action and reduces perceived benefits among caregivers. Furthermore, low staff motivation due to inadequate allowances was a recurrent qualitative theme in low uptake of HPV vaccine in adolescent girls. While not statistically significant in the multivariable model (AOR = 1.06, p = 0.645), this demotivation can lead to reduced outreach and compromised quality of service delivery, as noted by [32]. Continuous in-service training and supportive supervision for health workers coupled with adequate incentives, are essential to ensure well-informed and motivated personnel. 4.4 Outreach Strategies and Out-of-School Girls: The absence of clear government programs targeting out-of-school girls was identified as a significant barrier to low uptake of HPV Vaccine in adolescent girls (AOR = 0.97, p = 0.035) [14, 33, 34]. Qualitative data emphasized that seasonal activities (e.g., farming) prevent many girls from accessing information or vaccination sessions, and existing community mobilization is often inadequate. This represents a missed "cue to action" for a vulnerable population. This finding aligns with [14, 15,35] and underscores the need for flexible, diversified vaccination strategies beyond school-based delivery to reach all eligible adolescents, particularly those who are out of school or frequently absent. 4.5 Records Management and Waiting Times: Poor records management by health workers, while not statistically significant in the multivariable model (AOR = 0.95, p = 0.109) was a reported concern in quantitative findings (66.4%) and qualitative interviews. Fragmented or poorly maintained records make it difficult to track immunization status and follow up on missed doses. Interestingly, long waiting times were associated with a reduction in missed vaccinations (AOR = 0.75, p = 0.046) suggesting that highly motivated caregivers may persevere despite delays [14, 36]. This implies high self-efficacy within the HBM. However, conflicting reports indicate that long waits are often a deterrent. This complex relationship highlights the potential for high caregiver motivation to override a service barrier, but also the continued importance of optimizing service delivery efficiency. 5. Conclusion Health facility-related factors significantly contribute to the low HPV vaccine series completion rates in Rukiga District. Critical issues include vaccine stockouts and inadequate cold chain infrastructure, understaffing, limited health worker knowledge, and a lack of specific programs for out-of-school girls. These systemic weaknesses create significant perceived barriers, undermine cues to action, and reduce self-efficacy within the Health Belief Model framework. Addressing these challenges through strategic investments in logistics, human resources, continuous training, and inclusive outreach programs is crucial for enhancing service delivery and improving HPV vaccine coverage in similar low-resource settings. 6. Recommendations 6.1 Short-Term Recommendations (0–12 Months): To improve HPV vaccine uptake, it is crucial to provide continuous in-service training and supportive supervision for health workers, focusing on the vaccine schedule and eligibility. These addresses significant knowledge gaps linked to lower uptake (AOR = 0.94; p = 0.043). Additionally, recruiting and deploying more healthcare workers in understaffed facilities can enhance service capacity and reduce delays, responding to the identified association between understaffing and reduced uptake (AOR = 1.97; p = 0.006). 6.2 Medium-Term Recommendations (1–3 Years): To maintain vaccine availability and community trust, investments should prioritize cold chain infrastructure, buffer stock planning, and efficient delivery systems, addressing vaccine shortages and cold chain challenges that significantly reduce uptake (AOR = 1.75; p = 0.004). The national vaccination policy should transition from grade-based to age-based targeting to include mobile and out-of-school adolescents, as the lack of programs for these groups was a barrier (AOR = 0.97; p = 0.035). Moreover, developing an interoperable digital vaccine tracking system across health districts will help improve follow-up for mobile populations, mitigating poor record management issues linked to household relocation (AOR = 0.48; p = 0.003). 6.3 Implementation Considerations: To address persistent staffing shortages, governments and partners should implement retention packages, deploy adequate personnel, and support ongoing professional development. A stable, well-trained workforce is essential to sustaining vaccination efforts and community trust. This is supported by the significant association between staffing shortages and lower vaccine uptake (AOR = 0.53; 95% CI: 0.34–0.83; p = 0.005). 6.4 Stakeholder-Specific Recommendations: The Ministry of Health should invest in cold chain infrastructure and stock monitoring systems, with success measured by reduced stockouts, and revise HPV vaccination policy to adopt age-based eligibility, tracking district-level adoption rates. Healthcare workers should receive routine training on the HPV vaccine, communication skills, and side effect management; success can be tracked by numbers trained and improvements in uptake and caregiver satisfaction. Village Health Teams (VHTs) should focus on community outreach and follow-up for missed doses, aiming to improve caregiver knowledge and timely completion rates. 7. Study Limitations The study’s cross-sectional design limits causal inferences between factors and vaccine uptake, and self-reported data may be affected by recall or social desirability bias. Findings, while relevant to similar rural settings, stem from a single district, potentially limiting broader applicability. Despite training, interviewer bias cannot be fully excluded. Additionally, the study mainly captured perspectives from caregivers and frontline health workers; incorporating views from adolescents and policymakers could provide a more comprehensive understanding of barriers. 8. Future Research Directions Future studies should employ implementation science approaches to compare the effectiveness and cost-efficiency of school-based versus clinic-based vaccine delivery, including the impact of SMS reminders, using cluster randomized trials with economic evaluations to guide resource allocation. Investigating factors influencing health worker motivation in rural areas and testing targeted incentives or support systems could further enhance vaccination program engagement. 9. Cultural and Contextual Considerations This study highlights how Uganda’s cultural and religious environment shapes HPV vaccine uptake. While this manuscript focuses on health facility factors, the broader context of community mistrust (discussed in detail in other manuscripts) can impact the perceived trustworthiness of health facilities themselves. Efforts to strengthen health facilities must also consider rebuilding community trust to encourage utilization of available services. 10. Application and Policy Connections The results are in line with Uganda's 2025 Health Sector Development Plan (HSDP), namely the 25% increase in adolescent immunization coverage. Specific links consist of strengthening cooperation between the education sector for school-based delivery, assisting Village Health Teams (VHTs) with tracking and awareness initiatives for community outreach, and resolving obstacles for nomadic and out-of-school populations to ensure fair access. Addressing health facility barriers directly contributes to achieving these national goals. Example of an Implementation Framework: Making the Switch to Age-Based Vaccination . Administrative changes, such as updating Ministry of Health and Education joint protocols and school records with birth dates, are necessary. Capacity building involves teaching medical staff how to verify age and educating educators on new standards and channels for referrals. Monitoring coverage by age groups (lasting one year) and comparing uptake between girls who attend school and those who do not is essential. Launching trial projects in two to three districts to assess reach, adoption, and sustainability using the RE-AIM paradigm is recommended prior to nationwide implementation. 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 UNCS - 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 Ethics Approval and Consent to Participate . This study was conducted in accordance with the Declaration of Uganda National Council for Science and Technology and all applicable ethical guidelines for research involving human participants. Clearance to conduct this study was obtained from the Department of community at Kable, under registration number 2018/MPH/1659/W. Further ethical approval was granted by office of District Health officer Rukiga District and final clearance for data collection was obtained from the Uganda National Council for Science and Technology (UNCST), reference number MUST-2022-511. Informed consent was obtained from all participants prior to their involvement in the study. Consent for Publication . The researchers obtained written consent to use quotes from participants in publications. Data Availability . The primary study document, including the detailed information and dataset used and analyzed, is available upon reasonable request from the corresponding author. Competing Interests . The authors hereby declare that they have no competing interests. Funding . No external funding was received for this work Authors’ Contributions . Mbonigaba Rukarama Evarist (MRE) conceptualized the study, designed the study framework, led data collection and interpretation, prepared the manuscript and reviewed the paper. He is the principal investigator. Ronald Arineitwe Kibonire (RAK) as co-author, provided guidance throughout the study's conception, design, data collection and analysis phases, reviewed the manuscript and offered valuable feedback for refinement. Acknowledgements . We express our gratitude to the community of Rubanda for their participation in this study. Our sincere thanks go to the Office of the District Health Officer of Rukiga District for granting us permission to conduct the research in the district. We also extend special appreciation to the health facility staff of the selected facilities of Rukiga District and VHT members for their support in coordinating and mobilizing respondents for the study and even also giving their views as participants. References Reza, S., Anjum, R., Khandoker, R. Z., Khan, S. R., Islam, M. R., & Dewan, S. M. R. (2024). 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 oncology reports , 54 , 101460. Rayner, M., Welp, A., Stoler, M. H., & Cantrell, L. A. (2023, August). Cervical cancer screening recommendations: now and for the future. In Healthcare (Vol. 11, No. 16, p. 2273). MDPI. Alhamlan, F. S., Alfageeh, M. B., Al Mushait, M. A., Al-Badawi, I. A., & Al-Ahdal, M. N. (2021). Human papillomavirus-associated cancers. In Microbial Pathogenesis: Infection and Immunity (pp. 1-14). Cham: Springer International Publishing. Pimple, S., & Mishra, G. (2022). Cancer cervix: Epidemiology and disease burden. Cytojournal , 19 , 21. O'Neill, A. M., & Dwyer, R. (2023). Primary prevention of cervical cancer in women: Human papillomavirus vaccine. European Journal of Obstetrics and Gynecology and Reproductive Biology , 281 , 29-31. Padavu, S., Aichpure, P., Krishna Kumar, B., Kumar, A., Ratho, R., Sonkusare, S., ... & Rai, P. (2023). An insight into clinical and laboratory detections for screening and diagnosis of cervical cancer. Expert Review of Molecular Diagnostics , 23 (1), 29-40. Asasira, J., Lee, S., Tran, T. X. M., Mpamani, C., Wabinga, H., Jung, S. Y., ... & Cho, H. (2022). Infection-related and lifestyle-related cancer burden in Kampala, Uganda: projection of the future cancer incidence up to 2030. BMJ open , 12 (3), e056722. Yaney, A., Mladkova, N., & Quick, A. M. (2021). Clinical and Genomic Determinants of Survival in Ugandan Women With Cervical Cancer. International Journal of Radiation Oncology, Biology, Physics , 111 (3), S120. Huang, J., Deng, Y., Boakye, D., Tin, M. S., Lok, V., Zhang, L., ... & NCD Global Health Research Group. (2022). Global distribution, risk factors, and recent trends for cervical cancer: a worldwide country-level analysis. Gynecologic oncology , 164 (1), 85-92. Singh, D., Vignat, J., Lorenzoni, V., Eslahi, M., Ginsburg, O., Lauby-Secretan, B., ... & Vaccarella, S. (2023). Global estimates of incidence and mortality of cervical cancer in 2020: a baseline analysis of the WHO Global Cervical Cancer Elimination Initiative. The lancet global health , 11 (2), e197-e206. Li, Z., Liu, P., Yin, A., Zhang, B., Xu, J., Chen, Z., ... & Song, K. (2025). Global landscape of cervical cancer incidence and mortality in 2022 and predictions to 2030: The urgent need to address inequalities in cervical cancer. International Journal of Cancer , 157 (2), 288-297. Nakayita, R. M., Benyumiza, D., Nekesa, C., Misuk, I., Kyeswa, J., Nalubuuka, A., ... & Kumakech, E. (2023). Factors associated with uptake of human papilloma virus vaccine among school girls aged 9–14 years in Lira City northern Uganda: a cross-sectional study. BMC Women's Health , 23 (1), 362. 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, N. E., & Banura, C. (2021). Why don’t adolescent girls in a rural Uganda district initiate or complete routine 2-dose HPV vaccine series: Perspectives of adolescent girls, their caregivers, healthcare workers, community health workers and teachers. PloS one , 16 (6), e0253735. Patrick, L., Bakeera-Kitaka, S., Rujumba, J., & Malande, O. O. (2022). Encouraging improvement in HPV vaccination coverage among adolescent girls in Kampala, Uganda. PloS one , 17 (6), e0269655 District Health Information Software 2 (DHIS2)(2024). Rukiga District HPV vaccination data. Ministry of Health, Uganda. Wang, W., Kothari, S., Baay, M., Garland, S. M., Giuliano, A. R., Nygård, M., ... & Sundström, K. (2022). Real-world impact and effectiveness assessment of the quadrivalent HPV vaccine: a systematic review of study designs and data sources. Expert Review of Vaccines , 21 (2), 227-240. Agimas, M. C., Adugna, D. G., Derseh, N. M., Kassaw, A., Kassie, Y. T., Abate, H. K., & Mekonnen, C. K. (2024). Uptake of human papilloma virus vaccine and its determinants among females in East Africa: a systematic review and meta-analysis. BMC Public Health , 24 (1), 842. Asgedom, Y. S., Kebede, T. M., Seifu, B. L., Mare, K. U., Asmare, Z. A., Asebe, H. A., ... & Kassie, G. A. (2024). Human papillomavirus vaccination uptake and determinant factors among adolescent schoolgirls in sub-Saharan Africa: A systematic review and meta-analysis. Human vaccines & immunotherapeutics , 20 (1), 2326295. Rukiga NHPC, 2024. https://statistics.ubos.org/nphc/drilldown?subregion Jin, S. W., Lee, Y., & Brandt, H. M. (2023). Human papillomavirus (HPV) vaccination knowledge, beliefs, and hesitancy associated with stages of parental readiness for adolescent HPV vaccination: implications for HPV vaccination promotion. Tropical medicine and infectious disease , 8 (5), 251. . Wijayanti, K. E., Schütze, H., & MacPhail, C. (2021). Parents’ attitudes, beliefs and uptake of the school-based human papillomavirus (HPV) vaccination program in Jakarta, Indonesia–A quantitative study. Preventive Medicine Reports , 24 , 101651. 32. Elit, L., Ngalla, C., Afugchwi, G. M., Tum, E., Domgue, J. F., & Nouvet, E. (2022). Assessing knowledge, attitudes and belief toward HPV vaccination of parents with children aged 9–14 years in rural communities of Northwest Cameroon: a qualitative study. BMJ open , 12 (11), e068212. Jahrami, H., Trabelsi, K., Saif, Z., Manzar, M. D., Bahammam, A. S., & Vitiello, M. V. (2023). Reliability generalization meta-analysis of the Athens Insomnia Scale and its translations: Examining internal consistency and test-retest validity. Sleep Medicine , 111 , 133-145. Humnesa, H., Aboma, M., Dida, N., & Abebe, M. (2022). Knowledge and attitude regarding human papillomavirus vaccine and its associated factors among parents of daughters age between 9-14 years in central Ethiopia, 2021. Journal of Public Health in Africa , 13 (3), 2129. Feyisa, D. (2021). Cold chain maintenance and vaccine stock management practices at public health centers providing child immunization services in Jimma Zone, Oromia Regional State, Ethiopia: multi-centered, mixed method approach. Pediatric health, medicine and therapeutics , 359-372. Davies, B., Olivier, J., & Amponsah-Dacosta, E. (2023). Health systems determinants of delivery and uptake of maternal vaccines in low-and middle-income countries: a qualitative systematic review. Vaccines , 11 (4), 869. MacDonald, S. E., Kenzie, L., Letendre, A., Bill, L., Shea-Budgell, M., Henderson, R., ... & Nelson, G. (2023). Barriers and supports for uptake of human papillomavirus vaccination in Indigenous people globally: A systematic review. PLOS Global Public Health , 3 (1), e0001406. Milondzo, T., Meyer, J. C., Dochez, C., & Burnett, R. J. (2021). Misinformation drives low human papillomavirus vaccination coverage in South African girls attending private schools. Frontiers in Public Health , 9 , 598625. Neşe Yakşi, Berkhan Topaktaş Acibadem Universitesi Saglik Bilimleri Dergisi· 2023 Bakare, D., Gobbo, E., Akinsola, K. O., Bakare, A. A., Salako, J., Hanson, C., ... & King, C. (2024). Healthcare worker practices for HPV vaccine recommendation: A systematic review and meta-analysis. Human vaccines & immunotherapeutics , 20 (1), 2402122. Karanja-Chege, C. M. (2022). HPV vaccination in Kenya: the challenges faced and strategies to increase uptake. Frontiers in Public Health , 10 , 802947. Bitariho, G. K., Tuhebwe, D., Tigaiza, A., Nalugya, A., Ssekamatte, T., & Kiwanuka, S. N. (2023). Knowledge, perceptions and uptake of human papilloma virus vaccine among adolescent girls in Kampala, Uganda; a mixed-methods school-based study. BMC pediatrics , 23 (1), 368. Holroyd, T. A., Yan, S. D., Srivastava, V., Srivastava, A., Wahl, B., Morgan, C., ... & Jennings, M. C. (2022). Designing a pro-equity HPV vaccine delivery program for girls who have dropped out of school: community perspectives from uttar pradesh, India. Health promotion practice , 23 (6), 1039-1049. Asgedom, Y. S., Kebede, T. M., Seifu, B. L., Mare, K. U., Asmare, Z. A., Asebe, H. A., ... & Kassie, G. A. (2024). Human papillomavirus vaccination uptake and determinant factors among adolescent schoolgirls in sub-Saharan Africa: A systematic review and meta-analysis. Human vaccines & immunotherapeutics , 20 (1), 2326295. Yim, V. W. C., Wang, Q., Li, Y., Qin, C., Tang, W., Tang, S., ... & Wu, D. (2024). Between now and later: a mixed methods study of HPV vaccination delay among Chinese caregivers in urban Chengdu, China. BMC public health, 24(1), 183. Mbonigaba Rukarama Evarist. (2025). factors associated with low uptake of human papilloma virus (HPV) vaccination series in adolescent girls in R ukiga district. (research dissertation-not published). Kabale University. research dissertation submitted in partial fulfilment for the requirements of the award of master’s degree of public health of Kabale University.july, 2025 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-7597029","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":514183731,"identity":"ce762cea-a298-4018-8305-84a52568bb41","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":514183732,"identity":"102ae883-f73d-4b59-8977-c4d607e437bf","order_by":1,"name":"Ronald Arineitwe Kibonire","email":"","orcid":"","institution":"Kabale University","correspondingAuthor":false,"prefix":"","firstName":"Ronald","middleName":"Arineitwe","lastName":"Kibonire","suffix":""}],"badges":[],"createdAt":"2025-09-12 06:23:22","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7597029/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7597029/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":91315699,"identity":"b6258a7d-e067-460c-aa5e-178bd44119e5","added_by":"auto","created_at":"2025-09-15 08:12:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1704183,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7597029/v1/79df8b69-7d4f-4f0a-8c98-c7afc114cbb0.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Bridging the Service Gap – Health Facility Challenges in HPV Vaccine Uptake in Rural Uganda","fulltext":[{"header":"1. Introduction/Background","content":"\u003cp\u003eCervical cancer is a major global health issue, especially 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 and the most common gynaecological malignancy 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]. 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]. In Uganda, cervical cancer is the leading cause of cancer-related death in women, accounting for nearly 40% of all female cancer cases [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\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 four to five times higher than global standards [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eUganda initiated its first HPV vaccine demonstration program in 2006, assessing both school-based and age-based community delivery strategies [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The HPV vaccination was officially included in the nationwide routine immunization program in 2015 [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\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=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. This can be linked to inadequate follow-up mechanisms, poor record management, vaccine stockouts, low health worker motivation, misinformation, and insufficient community engagement. In Rukiga District, HPV1 adoption has remained quite high thanks to school-based outreach but the second dose absorption has fallen dramatically with recent data indicating a dropout rate of 23.49 percent [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. This is especially concerning because complete protection against HPV and prevention of cervical cancer requires completion of the two-dose regimen in adolescent females aged 9 to 14 years [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eHealth facilities play a pivotal role in the successful implementation and sustainment of vaccination programs. Operational inefficiencies, logistical challenges, and human resource limitations within health facilities can significantly impede vaccine delivery and uptake. Understanding these specific health facility-related barriers in rural settings like Rukiga is essential to inform targeted initiatives that strengthen the supply side of HPV vaccination. This study aims to identify and analyze these health facility factors to guide improvements in service delivery and ultimately increase HPV vaccine series completion.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\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 [17,18.19]. The cross-sectional design was chosen for its efficiency in assessing relationships between variables at a single point in time, providing a snapshot of the factors influencing HPV vaccine uptake.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e2.2 Study Setting.\u003c/h2\u003e\u003cp\u003eThe study was conducted in Rukiga District in southwestern Uganda, which borders Ntungamo District, the Republic of Rwanda, Kabale District, Rubanda District, and Rukungiri District. It has a total land area of 426.3 km2 and a total population of 132,355 people by sex, with 29,495 total households and a population density of 268/km2 [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The district was purposefully chosen due to its HPV vaccination program implementation, rural setting, limited access to health facilities, and integration into Uganda's Expanded Program for Immunization. Two sub-counties were selected because of their lower vaccination rates and accessibility issues.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e2.3 Study Population and Sampling.\u003c/h2\u003e\u003cp\u003e\u003cstrong\u003eQuantitative Study\u003c/strong\u003e\u003cp\u003eThe quantitative population included parents and guardians of adolescent girls aged 9\u0026ndash;14 years eligible to receive the HPV vaccine. They were chosen because they are ultimately in charge of making decisions about whether or not to accept or refuse the vaccine among their children. Minors (under 18) were excluded as primary respondents since vaccination would have to be given at school hours when they would be away from their parents or other caregivers [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eQualitative Study\u003c/strong\u003e\u003cp\u003eKey informants for the qualitative part of this study consisted of health workers and Village Health Team (VHT) members [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Health workers directly implement vaccination service delivery, while VHTs represent the immediate linkage of the health system to the population, providing health education and addressing myths and misconceptions.\u003c/p\u003e\u003c/p\u003e\u003cdiv id=\"Sec6\" class=\"Section3\"\u003e\u003ch2\u003e2.3.1 Sampling Technique/Method.\u003c/h2\u003e\u003cp\u003eA multistage sampling approach was used. Two sub-counties characterized by lower HPV vaccination rates and accessibility challenges were purposively selected. Parishes within these sub-counties were chosen through simple random sampling, and villages were then randomly selected. Households with adolescent girls aged 9 to 14 years, based on Village Health Team records, were selected proportionally to village size, followed by systematic random sampling, resulting in a final sample of 292 parents or caregivers. For qualitative data, 11 health workers involved in EPI and HPV vaccination, and 10 VHT members from the selected villages, were purposively sampled.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec7\" class=\"Section3\"\u003e\u003ch2\u003e2.3.2 Sample Size and Determination.\u003c/h2\u003e\u003cp\u003eThe sample size for the quantitative study was calculated using Cochrane\u0026rsquo;s equation, assuming a 95% confidence level and a P value of 0.05.\u003c/p\u003e\u003cp\u003en0​=Z\u003csup\u003e2\u003c/sup\u003epq​/ e\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eWhere:\u003c/p\u003e\u003cp\u003en0​ = required sample size\u003c/p\u003e\u003cp\u003eZ\u0026thinsp;=\u0026thinsp;Z-score (1.96 for 95% CI)\u003c/p\u003e\u003cp\u003ep\u0026thinsp;=\u0026thinsp;estimated proportion (0.5 for maximum variability)\u003c/p\u003e\u003cp\u003ee\u0026thinsp;=\u0026thinsp;Desired level of precision (0.05)\u003c/p\u003e\u003cp\u003eq\u0026thinsp;=\u0026thinsp;1\u0026thinsp;\u0026minus;\u0026thinsp;p\u003c/p\u003e\u003cp\u003eThis yielded n0​=385.\u003c/p\u003e\u003cp\u003eFor a finite population (N\u0026thinsp;=\u0026thinsp;1200 households), the Cochran sample size correction was applied:\u003c/p\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;1\u0026thinsp;+\u0026thinsp;N(n0​\u0026minus;1) /​n0​​\u003c/p\u003e\u003cp\u003eSubstituting the values:\u003c/p\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;1\u0026thinsp;+\u0026thinsp;1200(385\u0026thinsp;\u0026minus;\u0026thinsp;1) ​/385​=1\u0026thinsp;+\u0026thinsp;1200(384) ​/385​=1\u0026thinsp;+\u0026thinsp;0.32/385​=1.32/385​=291.666667\u0026thinsp;=\u0026thinsp;292\u003c/p\u003e\u003cp\u003eThus, 292 partipants were included in the study as the adjusted sample size.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section3\"\u003e\u003ch2\u003e2.3.3 Inclusion and Exclusion Criteria.\u003c/h2\u003e\u003cp\u003e\u003cstrong\u003eInclusion\u003c/strong\u003e\u003cp\u003eParents or primary caregivers of adolescent girls aged 9\u0026ndash;14 years found at home from selected sub-counties in Rukiga District who provided informed consent.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eExclusion\u003c/strong\u003e\u003cp\u003eHouseholds where caregivers had significant cognitive or hearing impairments, and child-headed households, due to challenges in obtaining reliable responses.\u003c/p\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003e2.4 Study Variables.\u003c/h2\u003e\u003cp\u003e\u003cstrong\u003eDependent variable\u003c/strong\u003e\u003cp\u003eLow uptake of HPV vaccination series.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eIndependent variables\u003c/b\u003e: Health facility barriers: Poor documentation, limited service providers' knowledge, lack of strategies targeting out-of-school girls, shortages of vaccine supplies, limited social mobilization, unreliable transportation, lack of staff motivation, and shortage of healthcare workers.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003e2.5 Data Collection Methods.\u003c/h2\u003e\u003cp\u003eA mixed-methods approach was used, combining semi-structured interviewer-administered questionnaires for quantitative data and Key Informant Interviews (KIIs) for qualitative data. Ten trained research assistants conducted household visits, and the semi-structured design allowed for standardized responses and in-depth insights.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section3\"\u003e\u003ch2\u003e2.5.1 Development of Interview Guides.\u003c/h2\u003e\u003cp\u003eThe questionnaire and Key interview guides were developed specifically for this study, drawing from a comprehensive review of existing literature on HPV vaccine uptake and adapting relevant items from tools used in similar studies to enhance content validity. These instruments were designed by the principal investigator, translated into the predominant local language spoken in the study area, and subsequently back-translated into English to ensure linguistic and conceptual accuracy [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. These tools were newly developed for this research and have not been previously published elsewhere.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section3\"\u003e\u003ch2\u003e2.5.2 Pre-testing Tools.\u003c/h2\u003e\u003cp\u003eTools were piloted in Kashaki Village, an external site, with 40 parents/caretakers and in-depth interviews with three health workers and two VHT members. Pre-testing ensured clarity, cultural appropriateness, and allowed for revisions and standardization of the tools. Interviews were conducted in Rukiga or Runyankole for parents/caretakers, and English for health workers.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section3\"\u003e\u003ch2\u003e2.5.3 Recruitment and Training of Research Assistants.\u003c/h2\u003e\u003cp\u003eTen research assistants with good knowledge of English and Rukiga-Runyankole, medical backgrounds, and interview experience were recruited and trained. They were supervised daily to ensure accuracy and completeness of data collection.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section3\"\u003e\u003ch2\u003e2.5.4 Data Collection Tools and Field Editing.\u003c/h2\u003e\u003cp\u003eData was collected using pre-tested semi-structured questionnaires and checklists. Field editing was performed daily to ensure accuracy, completeness, and address non-responses.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003e2.6 Validity and Reliability of the Research Instrument:2.6.1 Quantitative Data.\u003c/h2\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eValidity\u003c/b\u003e: Content validity was ensured through expert consultations and literature review, and construct validity was assessed through pilot testing. Face validity was ensured by involving VHT members in reviewing the instrument for clarity, cultural appropriateness and relevance.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eReliability\u003c/b\u003e: Confirmed through Cronbach\u0026rsquo;s alpha (0.72 to 0.83) indicating good internal consistency, and test-retest reliability (0.82) showing strong stability over time [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cdiv id=\"Sec16\" class=\"Section3\"\u003e\u003ch2\u003e2.6.2 Qualitative Data.\u003c/h2\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eValidity\u003c/b\u003e: Member checking was employed by presenting preliminary results to selected participants to confirm accuracy of interpretations.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eReliability\u003c/b\u003e: Intercoder reliability was applied, with multiple researchers independently coding transcripts and resolving discrepancies through consensus.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003e2.7 Data Quality Control.\u003c/h2\u003e\u003cp\u003eQuality control was ensured through adequate questionnaires, proper identification of key informants, training of research assistants, daily supervision, review, and entry of data.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003e2.8 Data Management and Analysis.\u003c/h2\u003e\u003cp\u003e\u003cb\u003eQuantitative Data Analysis\u003c/b\u003e Data was checked for completeness and accuracy, entered into Epi-Info, and then transferred to SPSS for analysis. Univariate analysis generated frequency tables and descriptive parameters. Bivariate analysis compared the dependent variable with independent variables using confidence intervals and p-values. Multivariable logistic regression analysis adjusted for confounding and determined factors associated with HPV vaccine uptake, including all variables from bivariate analysis regardless of their initial p-values, to account for potential confounders or clinically/theoretically significant variables.\u003c/p\u003e\u003cp\u003e\u003cb\u003eQualitative Data Analysis.\u003c/b\u003e\u003c/p\u003e\u003cp\u003e Open-ended responses were systematically coded by allocating them to frequent themes, allowing structured interpretation and identification of trends and patterns between participant responses.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003e2.9 Ethical Consideration.\u003c/h2\u003e\u003cp\u003e Approval was obtained from Kabale University and Mbarara University Research Ethics Committee. Permission was also sought from the Rukiga District Health Officer. Respondents were informed about the study objectives and process, and informed consent was obtained, with participation being voluntary and confidentiality maintained.\u003c/p\u003e\u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003eThe study involved 292 respondents and the overall completion rate for the two-dose HPV vaccination series in Rukiga District was 27.49% [\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e\n\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\n \u003ch2\u003e3.1 Health Factors Associated with Low Uptake: Quantitative Findings (Table 5)\u003c/h2\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Taba\" border=\"1\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eStatement\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariable option\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003ePoor records management.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e194 (66.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e98 (33.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eLimited knowledge of HPV vaccination schedule\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e191 (65.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e101 (34.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eLack of clear programs by the government which target girls out of school.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e198 (67.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e94 (32.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eShortage of vaccines and inadequate cold chain infrastructure.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e193 (66.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e99 (33.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eUuntimely transportation of staff to vaccination centre\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e214 (73.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e78 (26.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eLack of staff motivation such as the outreach allowances.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e215 (73.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e77 (26.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eUnderstaffing of healthcare workers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e168 (57.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e124 (42.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\"\u003e\u003cstrong\u003eSource: Primary data, 2022\u003c/strong\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003eFrom table above, sseveral health system challenges were identified as contributing factors to low HPV vaccine uptake. These included poor records management by health workers (66.4%), limited knowledge of the HPV vaccination schedule among health workers (65.4%), and the absence of clear government programs specifically targeting out-of-school girls (66.1%). Vaccine shortages and inadequate cold chain infrastructure were also cited by 66.1% of respondents as obstacles. Additionally, untimely transportation of staff and vaccines was seen as a significant issue by 73.3%, leading to community uncertainty. Lack of staff motivation, such as the absence of outreach allowances, was indicated by 73.6% as a barrier to immunization completion, while understaffing within healthcare facilities was believed by 57.5% to limit the implementation of HPV vaccination programs.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eBivariate Analysis (Table\u0026nbsp;1)\u003c/strong\u003e:\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tabb\" border=\"1\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHealth factors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eValue option\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eP -Value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003ePoor records management by health workers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e194\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.951\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e0.109\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.112\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eLimited knowledge of HPV vaccination schedule by the health workers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e191\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e0.043\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e101\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.15\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eLack of clear programs by the government which target girls out of school.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e198\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e0.035\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.06\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eShortage of vaccines and inadequate cold chain infrastructure for storing HPV vaccines.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e193\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.748\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.519\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eUntimely transportation of staff and vaccines\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e214\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.931\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e0.574\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.248\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eLack of staff motivation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e125\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.063\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e0.645\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.855\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eUnderstaffing of healthcare workers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e168\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.967\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e0.006\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e124\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.577\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\"\u003e\u003cstrong\u003eSource\u003c/strong\u003e: Primary data, 2022\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003eFrom table one above, key health system barriers to HPV vaccine uptake include limited health worker knowledge (OR\u0026thinsp;=\u0026thinsp;0.94, p\u0026thinsp;=\u0026thinsp;0.043) and lack of government programs for out-of-school girls (OR\u0026thinsp;=\u0026thinsp;0.97, p\u0026thinsp;=\u0026thinsp;0.035), both significantly lowering uptake. Vaccine shortages and cold chain issues (OR\u0026thinsp;=\u0026thinsp;1.75, p\u0026thinsp;=\u0026thinsp;0.004) and understaffing (OR\u0026thinsp;=\u0026thinsp;1.97, p\u0026thinsp;=\u0026thinsp;0.006) significantly increased the risk of low vaccination rates. Other factors like poor records management and transportation delays were noted but not statistically significant.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMultivariable Logistic Regression Analysis (Table\u0026nbsp;2)\u003c/strong\u003e\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tabc\" border=\"1\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFactor Category\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariable Option\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eOR (95% CI)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDemographic Factors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge of Caretaker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20\u0026ndash;30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.65 (0.32\u0026ndash;1.31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.220\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31\u0026ndash;40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e107\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.94 (0.56\u0026ndash;1.58)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.820\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e41\u0026ndash;50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e125\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.42 (0.85\u0026ndash;2.36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.180\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e50+ (Ref)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGender of Caretaker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e149\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.18 (0.85\u0026ndash;5.57)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.096\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMale (Ref)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCaretaker Relationship\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMother\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e128\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.70 (1.05\u0026ndash;2.75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.030\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOthers (Ref)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEducation Level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.19 (0.04\u0026ndash;0.87)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.033\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrimary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.50 (0.30\u0026ndash;0.83)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.007\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSecondary+ (Ref)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOccupation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePeasant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e111\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.49 (0.28\u0026ndash;0.87)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.013\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEmployed/Business (Ref)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMarital Status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e134\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.43 (0.73\u0026ndash;2.80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.280\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNot Married (Ref)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDistance to Health Center\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDistance to Health Center\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;1 km\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNot estimable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u0026ndash;3 km (Ref)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e110\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u0026ndash;6 km\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.96 (0.53\u0026ndash;1.74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.892\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ge;\u0026thinsp;6 km\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.03 (0.43\u0026ndash;2.44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.947\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNot aware\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.87 (0.05\u0026ndash;15.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.921\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eClass Level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eP2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.17\u0026ndash;4.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.87\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eP3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.51\u0026ndash;1.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.83\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eP4 (Reference)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e107\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.00 (Ref)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eP5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.49\u0026ndash;1.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.78\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eP6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.49\u0026ndash;2.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.87\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eP7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.48\u0026ndash;2.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.74\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIndividual Factors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInadequate knowledge about HPV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e207\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.28 (0.89\u0026ndash;1.84)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.114\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eChange of residence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e110\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.50 (0.37\u0026ndash;0.69)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e182\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAbsenteeism / dropout\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e175\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.73 (0.59\u0026ndash;0.91)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.037\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e117\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCaregiver discouragement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e182\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.85 (0.69\u0026ndash;1.05)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.222\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e110\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePoor road infrastructure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e209\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.39 (0.92\u0026ndash;2.10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.108\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFear of injection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e201\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.21 (0.83\u0026ndash;1.77)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.311\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePeer/Caregiver discouragement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e197\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.17 (0.79\u0026ndash;1.72)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.420\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHealth System Factors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePoor records management\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e194\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.95 (0.72\u0026ndash;1.26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.109\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLimited knowledge by health workers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e191\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.94 (0.70\u0026ndash;1.24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.043\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e101\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo gov\u0026rsquo;t program for out of school girls\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e198\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.97 (0.73\u0026ndash;1.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.035\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eShortage/cold chain issues\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e193\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.75 (1.04\u0026ndash;2.93)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUntimely transport\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e214\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.93 (0.74\u0026ndash;1.17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.574\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLow staff motivation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e125\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.06 (0.80\u0026ndash;1.41)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.645\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnderstaffing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e168\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.97 (1.05\u0026ndash;3.68)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.006\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e124\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCommunity Factors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRumors / misconceptions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e198\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.033\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eReligious/cultural opposition\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e176\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.031\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e116\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMistrust of government\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e176\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.009\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e116\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBusy stakeholder schedules\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e177\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.190\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e115\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLong waiting time\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e185\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.046\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e107\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eKnowledge Factors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHeard about HPV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e269\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.65 (1.89\u0026ndash;11.45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eKnowledge of eligible age\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCorrect (9\u0026ndash;14 yrs)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e170\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.29 (1.47\u0026ndash;3.56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBelief that vaccination is right\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e262\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.57 (1.52\u0026ndash;8.41)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.003\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eKnowledge of correct doses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCorrect (2 doses)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.20 (1.25\u0026ndash;3.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.005\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNumber of doses received\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOne dose\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e149\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.20 (0.80\u0026ndash;1.80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.370\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTwo doses (Ref)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDon\u0026rsquo;t know\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.62 (0.35\u0026ndash;1.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.110\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\"\u003e\u003cstrong\u003eSource\u003c/strong\u003e: Primary data, 2022\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003eFrom Table 2 above, sseveral health system factors significantly influence HPV vaccine uptake. Limited knowledge of the vaccination schedule among health workers was associated with lower uptake (OR\u0026thinsp;=\u0026thinsp;0.94, p\u0026thinsp;=\u0026thinsp;0.043), as was the absence of government programs targeting out-of-school girls (OR\u0026thinsp;=\u0026thinsp;0.97, p\u0026thinsp;=\u0026thinsp;0.035). Vaccine shortages and inadequate cold chain infrastructure increased the likelihood of low vaccination rates (OR\u0026thinsp;=\u0026thinsp;1.75, p\u0026thinsp;=\u0026thinsp;0.004), as did understaffing in healthcare facilities (OR\u0026thinsp;=\u0026thinsp;1.97, p\u0026thinsp;=\u0026thinsp;0.006). Although issues like poor records management and transportation delays were commonly reported, they were not statistically significant predictors of vaccine uptake in the analysis.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\n \u003ch2\u003e3.2 Qualitative Data Analysis (Thematic Presentation, Table 3)\u003c/h2\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tabd\" border=\"1\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTheme\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSubtheme\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCategories\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIndividual-Level Barriers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLack of Awareness Among Caregivers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e- Uncertainty about vaccination eligibility (e.g., belief that only girls below 10 qualify).\u003c/p\u003e\n \u003cp\u003e- Limited knowledge about the HPV vaccine.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"5\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAbsenteeism and School Dropout\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e- School absence due to unpaid fees, household responsibilities, or early menstruation.\u003c/p\u003e\n \u003cp\u003e- Some parents keep children home for farm work.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRelocation and School Transfers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e- Families frequently relocate, disrupting vaccine follow-ups.\u003c/p\u003e\n \u003cp\u003e- Parents are often uninformed about vaccination continuity\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePhysical Barriers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e- Hard-to-reach areas with poor road networks limit vaccine access.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFear of Injection Pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-Adolescents hesitate to complete the HPV vaccination\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNegative Influence from Caregivers or Peers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-Care givers hold misconceptions.\u003c/p\u003e\n \u003cp\u003e-Peers sharing stories of adverse effects or express skepticism\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"8\"\u003e\n \u003cp\u003eHealth facility barriers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLimited Knowledge Among Healthcare Workers, VHTs, and Teachers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e- Unclear understanding of HPV vaccination guidelines.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCold Chain and Logistical Challenges\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e- Shortages of ice packs limit the number of doses transported.\u003c/p\u003e\n \u003cp\u003e- Some facilities lack refrigeration for proper vaccine storage.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInadequate Community Engagement and Mobilization\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e- Shortages of ice packs limit the number of doses transported.\u003c/p\u003e\n \u003cp\u003e- Some facilities lack refrigeration for proper vaccine storage\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInadequate Community Engagement and Mobilization\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e- Seasonal activities prevent girls from accessing vaccine information.\u003c/p\u003e\n \u003cp\u003e- Many families remain unaware of vaccination campaigns.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTransportation Challenges\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e- Lack of reliable transport disrupts vaccine delivery.\u003c/p\u003e\n \u003cp\u003e- Canceled or delayed vaccination sessions cause frustration.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eExpectations of Monetary Incentives\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e- Healthcare workers and teachers are demotivated by inadequate allowances\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStaff Shortages\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e- Limited personnel available for vaccination services.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnfriendly Behavior from Healthcare Workers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e- Some healthcare workers exhibit rude or discouraging attitudes.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eCommunity Level Barriers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRumors and Misconceptions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBeliefs that the vaccine promotes early sexual activity.\u003c/p\u003e\n \u003cp\u003e- Concerns about infertility and reproductive health risks.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTraditional and Religious Beliefs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e- Perceptions that vaccination contradicts cultural or religious norms.\u003c/p\u003e\n \u003cp\u003e- Some believe being vaccinated violates traditional rules.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003eIn the table 3 above, the qualitative interviews with health workers and VHTs revealed several barriers within health facilities that hinder HPV vaccine uptake. Many healthcare providers, VHTs, and teachers lacked updated knowledge about HPV vaccination guidelines, which weakened community mobilization and caregiver education. Persistent vaccine stockouts and inadequate cold chain infrastructure led to missed opportunities. Community engagement was insufficient, with many households unaware of vaccination schedules, especially during busy farming seasons. Transportation challenges, including unreliable vehicles and poor road conditions, disrupted vaccine delivery. Low staff motivation due to inadequate incentives, staff shortages causing delays, and unfriendly behavior from some healthcare workers further discouraged vaccine uptake.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eHealth facility factors emerged as critical impediments to HPV vaccine uptake in Rukiga District, directly affecting service accessibility, quality, and community trust, consistent with the Health Belief Model (HBM) [14, 25].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.1 Vaccine Logistics and Cold Chain Management:\u003c/strong\u003eThe quantitative finding that vaccine shortages and inadequate cold chain infrastructure significantly increased the odds of low uptake of HPV vaccine in adolescent girls (AOR = 1.75, p = 0.004) was strongly supported by qualitative data [25, 26, 17]. Caregivers expressed frustration and loss of trust when vaccines were unavailable after long travel or when health workers lacked supplies, increasing perceived barriers and undermining cues to action and self-efficacy. These findings align with\u0026nbsp;[14, 25, 28]\u0026nbsp;who similarly highlight logistical issues as major barriers to vaccine delivery. Strengthening supply chain management, investing in robust cold chain infrastructure, and ensuring consistent vaccine availability are paramount to building trust and improving consistent access.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.2 Human Resources and Staffing:\u003c/strong\u003eUnderstaffing of healthcare workers nearly doubled the odds of missed vaccinations (AOR = 1.97, p = 0.006). Qualitative insights revealed how staffing shortages disrupt outreach activities, lead to long waiting times, and limit caregivers’ access to services, thereby increasing perceived barriers and weakening cues to action. This is consistent with findings by [14,25]. While [29]\u0026nbsp;suggest misinformation might be more relevant in resource-rich areas, in contexts like Rukiga where access is constrained, staffing is a key operational priority. Policymakers must prioritize the recruitment, training, and retention of healthcare workers, particularly in underserved areas, to enhance service capacity and reduce delays.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.3 Health Worker Knowledge and Motivation:\u003c/strong\u003eLimited knowledge among health personnel regarding the HPV vaccination schedule was a significant obstacle (AOR=0.94, p=0.043) [30]. Qualitative data indicated that some health workers, VHTs, and teachers lacked updated knowledge, diminishing their ability to effectively mobilize communities and educate caregivers [30, 31]. This weakens the cues to action and reduces perceived benefits among caregivers. Furthermore, low staff motivation due to inadequate allowances was a recurrent qualitative theme in low uptake of HPV vaccine in adolescent girls. While not statistically significant in the multivariable model (AOR = 1.06, p = 0.645), this demotivation can lead to reduced outreach and compromised quality of service delivery, as noted by [32]. Continuous in-service training and supportive supervision for health workers coupled with adequate incentives, are essential to ensure well-informed and motivated personnel.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.4 Outreach Strategies and Out-of-School Girls:\u003c/strong\u003eThe absence of clear government programs targeting out-of-school girls was identified as a significant barrier to low uptake of HPV Vaccine in adolescent girls (AOR = 0.97, p = 0.035) [14, 33, 34]. Qualitative data emphasized that seasonal activities (e.g., farming) prevent many girls from accessing information or vaccination sessions, and existing community mobilization is often inadequate. This represents a missed \"cue to action\" for a vulnerable population. This finding aligns with [14, 15,35] and underscores the need for flexible, diversified vaccination strategies beyond school-based delivery to reach all eligible adolescents, particularly those who are out of school or frequently absent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.5 Records Management and Waiting Times:\u003c/strong\u003ePoor records management by health workers, while not statistically significant in the multivariable model (AOR = 0.95, p = 0.109) was a reported concern in quantitative findings (66.4%) and qualitative interviews. Fragmented or poorly maintained records make it difficult to track immunization status and follow up on missed doses. Interestingly, long waiting times were associated with a reduction in missed vaccinations (AOR = 0.75, p = 0.046) suggesting that highly motivated caregivers may persevere despite delays [14, 36]. This implies high self-efficacy within the HBM. However, conflicting reports indicate that long waits are often a deterrent. This complex relationship highlights the potential for high caregiver motivation to override a service barrier, but also the continued importance of optimizing service delivery efficiency.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eHealth facility-related factors significantly contribute to the low HPV vaccine series completion rates in Rukiga District. Critical issues include vaccine stockouts and inadequate cold chain infrastructure, understaffing, limited health worker knowledge, and a lack of specific programs for out-of-school girls. These systemic weaknesses create significant perceived barriers, undermine cues to action, and reduce self-efficacy within the Health Belief Model framework. Addressing these challenges through strategic investments in logistics, human resources, continuous training, and inclusive outreach programs is crucial for enhancing service delivery and improving HPV vaccine coverage in similar low-resource settings.\u003c/p\u003e"},{"header":"6. Recommendations","content":"\u003cp\u003e\u003cstrong\u003e6.1 Short-Term Recommendations (0–12 Months):\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo improve HPV vaccine uptake, it is crucial to provide continuous in-service training and supportive supervision for health workers, focusing on the vaccine schedule and eligibility. These addresses significant knowledge gaps linked to lower uptake (AOR = 0.94; p = 0.043). Additionally, recruiting and deploying more healthcare workers in understaffed facilities can enhance service capacity and reduce delays, responding to the identified association between understaffing and reduced uptake (AOR = 1.97; p = 0.006).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e6.2 Medium-Term Recommendations (1–3 Years):\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo maintain vaccine availability and community trust, investments should prioritize cold chain infrastructure, buffer stock planning, and efficient delivery systems, addressing vaccine shortages and cold chain challenges that significantly reduce uptake (AOR = 1.75; p = 0.004). The national vaccination policy should transition from grade-based to age-based targeting to include mobile and out-of-school adolescents, as the lack of programs for these groups was a barrier (AOR = 0.97; p = 0.035). Moreover, developing an interoperable digital vaccine tracking system across health districts will help improve follow-up for mobile populations, mitigating poor record management issues linked to household relocation (AOR = 0.48; p = 0.003).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e6.3 Implementation Considerations:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo address persistent staffing shortages, governments and partners should implement retention packages, deploy adequate personnel, and support ongoing professional development. A stable, well-trained workforce is essential to sustaining vaccination efforts and community trust. This is supported by the significant association between staffing shortages and lower vaccine uptake (AOR = 0.53; 95% CI: 0.34–0.83; p = 0.005).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e6.4 Stakeholder-Specific Recommendations:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Ministry of Health should invest in cold chain infrastructure and stock monitoring systems, with success measured by reduced stockouts, and revise HPV vaccination policy to adopt age-based eligibility, tracking district-level adoption rates. Healthcare workers should receive routine training on the HPV vaccine, communication skills, and side effect management; success can be tracked by numbers trained and improvements in uptake and caregiver satisfaction. Village Health Teams (VHTs) should focus on community outreach and follow-up for missed doses, aiming to improve caregiver knowledge and timely completion rates.\u003c/p\u003e"},{"header":"7. Study Limitations","content":"\u003cp\u003eThe study’s cross-sectional design limits causal inferences between factors and vaccine uptake, and self-reported data may be affected by recall or social desirability bias. Findings, while relevant to similar rural settings, stem from a single district, potentially limiting broader applicability. Despite training, interviewer bias cannot be fully excluded. Additionally, the study mainly captured perspectives from caregivers and frontline health workers; incorporating views from adolescents and policymakers could provide a more comprehensive understanding of barriers.\u003c/p\u003e"},{"header":"8. Future Research Directions","content":"\u003cp\u003eFuture studies should employ implementation science approaches to compare the effectiveness and cost-efficiency of school-based versus clinic-based vaccine delivery, including the impact of SMS reminders, using cluster randomized trials with economic evaluations to guide resource allocation. Investigating factors influencing health worker motivation in rural areas and testing targeted incentives or support systems could further enhance vaccination program engagement.\u003c/p\u003e"},{"header":"9. Cultural and Contextual Considerations","content":"\u003cp\u003eThis study highlights how Uganda\u0026rsquo;s cultural and religious environment shapes HPV vaccine uptake. While this manuscript focuses on health facility factors, the broader context of community mistrust (discussed in detail in other manuscripts) can impact the perceived trustworthiness of health facilities themselves. Efforts to strengthen health facilities must also consider rebuilding community trust to encourage utilization of available services.\u003c/p\u003e"},{"header":"10. Application and Policy Connections","content":"\u003cp\u003eThe results are in line with Uganda's 2025 Health Sector Development Plan (HSDP), namely the 25% increase in adolescent immunization coverage. Specific links consist of strengthening cooperation between the education sector for school-based delivery, assisting Village Health Teams (VHTs) with tracking and awareness initiatives for community outreach, and resolving obstacles for nomadic and out-of-school populations to ensure fair access. Addressing health facility barriers directly contributes to achieving these national goals.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eExample of an Implementation Framework: Making the Switch to Age-Based Vaccination\u003c/strong\u003e\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAdministrative changes, such as updating Ministry of Health and Education joint protocols and school records with birth dates, are necessary. Capacity building involves teaching medical staff how to verify age and educating educators on new standards and channels for referrals. Monitoring coverage by age groups (lasting one year) and comparing uptake between girls who attend school and those who do not is essential. Launching trial projects in two to three districts to assess reach, adoption, and sustainability using the RE-AIM paradigm is recommended prior to nationwide implementation.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAOR - \u0026nbsp; \u0026nbsp;Adjusted Odds Ratio\u003c/p\u003e\n\u003cp\u003eCOR - \u0026nbsp; \u0026nbsp; Crude Odds Ratio\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEPI - \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Expanded Programme on Immunization and vaccination\u003c/p\u003e\n\u003cp\u003eHBM - \u0026nbsp; \u0026nbsp;Health Belief Model\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHPV - \u0026nbsp; \u0026nbsp; \u0026nbsp; Human Papilloma Virus\u003c/p\u003e\n\u003cp\u003eMUST- Mbarara University of Science and Technology\u003c/p\u003e\n\u003cp\u003eUNCS - Uganda National Council for Science and Technology\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOR \u0026nbsp; \u0026nbsp; - \u0026nbsp; Odds Ratio\u003c/p\u003e\n\u003cp\u003eREC \u0026nbsp; - \u0026nbsp; Research Ethics Committee \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSPSS - \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003cstrong\u003eStatistical Package for the Social Sciences\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eVHT - \u0026nbsp; \u0026nbsp; Village Health Team\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate\u003c/strong\u003e\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;This study was conducted in accordance with the Declaration of Uganda National Council for Science and Technology and all applicable ethical guidelines for research involving human participants. Clearance to conduct this study was obtained from the Department of community at Kable, under registration number 2018/MPH/1659/W. Further ethical approval was granted by office of District Health officer Rukiga District and final clearance for data collection was obtained from the Uganda National Council for Science and Technology (UNCST), reference number MUST-2022-511. Informed consent was obtained from all participants prior to their involvement in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe researchers obtained written consent to use quotes from participants in publications.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;The primary study document, including the detailed information and dataset used and analyzed, is available upon reasonable request from the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;The authors hereby declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;No external funding was received for this work\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ Contributions\u003c/strong\u003e\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Mbonigaba Rukarama Evarist (MRE) conceptualized the study, designed the study framework, led data collection and interpretation, prepared the manuscript and reviewed the paper. He is the principal investigator. Ronald Arineitwe Kibonire (RAK) as co-author, provided guidance throughout the study's conception, design, data collection and analysis phases, reviewed the manuscript and offered valuable feedback for refinement.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;We express our gratitude to the community of Rubanda for their participation in this study. Our sincere thanks go to the Office of the District Health Officer of Rukiga District for granting us permission to conduct the research in the district. We also extend special appreciation to the health facility staff of the selected facilities of Rukiga District and VHT members for their support in coordinating and mobilizing respondents for the study and even also giving their views as participants.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eReza, S., Anjum, R., Khandoker, R. Z., Khan, S. R., Islam, M. R., \u0026amp; Dewan, S. M. R. (2024). Public health concern-driven insights and response of low-and middle-income nations to the World health Organization call for cervical cancer risk eradication. \u003cem\u003eGynecologic oncology reports\u003c/em\u003e, \u003cem\u003e54\u003c/em\u003e, 101460.\u003c/li\u003e\n \u003cli\u003e\u0026nbsp;Rayner, M., Welp, A., Stoler, M. H., \u0026amp; Cantrell, L. A. (2023, August). Cervical cancer screening recommendations: now and for the future. In \u003cem\u003eHealthcare\u003c/em\u003e (Vol. 11, No. 16, p. 2273). 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Assessing knowledge, attitudes and belief toward HPV vaccination of parents with children aged 9\u0026ndash;14 years in rural communities of Northwest Cameroon: a qualitative study. \u003cem\u003eBMJ open\u003c/em\u003e, \u003cem\u003e12\u003c/em\u003e(11), e068212.\u003c/li\u003e\n \u003cli\u003eJahrami, H., Trabelsi, K., Saif, Z., Manzar, M. D., Bahammam, A. S., \u0026amp; Vitiello, M. V. (2023). Reliability generalization meta-analysis of the Athens Insomnia Scale and its translations: Examining internal consistency and test-retest validity. \u003cem\u003eSleep Medicine\u003c/em\u003e, \u003cem\u003e111\u003c/em\u003e, 133-145.\u003c/li\u003e\n \u003cli\u003eHumnesa, H., Aboma, M., Dida, N., \u0026amp; Abebe, M. (2022). Knowledge and attitude regarding human papillomavirus vaccine and its associated factors among parents of daughters age between 9-14 years in central Ethiopia, 2021. \u003cem\u003eJournal of Public Health in Africa\u003c/em\u003e, \u003cem\u003e13\u003c/em\u003e(3), 2129.\u003c/li\u003e\n \u003cli\u003eFeyisa, D. (2021). Cold chain maintenance and vaccine stock management practices at public health centers providing child immunization services in Jimma Zone, Oromia Regional State, Ethiopia: multi-centered, mixed method approach. \u003cem\u003ePediatric health, medicine and therapeutics\u003c/em\u003e, 359-372.\u003c/li\u003e\n \u003cli\u003eDavies, B., Olivier, J., \u0026amp; Amponsah-Dacosta, E. (2023). Health systems determinants of delivery and uptake of maternal vaccines in low-and middle-income countries: a qualitative systematic review. \u003cem\u003eVaccines\u003c/em\u003e, \u003cem\u003e11\u003c/em\u003e(4), 869.\u003c/li\u003e\n \u003cli\u003eMacDonald, S. E., Kenzie, L., Letendre, A., Bill, L., Shea-Budgell, M., Henderson, R., ... \u0026amp; Nelson, G. (2023). Barriers and supports for uptake of human papillomavirus vaccination in Indigenous people globally: A systematic review. \u003cem\u003ePLOS Global Public Health\u003c/em\u003e, \u003cem\u003e3\u003c/em\u003e(1), e0001406.\u003c/li\u003e\n \u003cli\u003eMilondzo, T., Meyer, J. C., Dochez, C., \u0026amp; Burnett, R. J. (2021). Misinformation drives low human papillomavirus vaccination coverage in South African girls attending private schools. \u003cem\u003eFrontiers in Public Health\u003c/em\u003e, \u003cem\u003e9\u003c/em\u003e, 598625.\u003c/li\u003e\n \u003cli\u003eNeşe Yakşi, Berkhan Topaktaş Acibadem Universitesi Saglik Bilimleri Dergisi\u0026middot; 2023\u003c/li\u003e\n \u003cli\u003eBakare, D., Gobbo, E., Akinsola, K. O., Bakare, A. A., Salako, J., Hanson, C., ... \u0026amp; King, C. (2024). Healthcare worker practices for HPV vaccine recommendation: A systematic review and meta-analysis. \u003cem\u003eHuman vaccines \u0026amp; immunotherapeutics\u003c/em\u003e, \u003cem\u003e20\u003c/em\u003e(1), 2402122.\u003c/li\u003e\n \u003cli\u003eKaranja-Chege, C. M. (2022). HPV vaccination in Kenya: the challenges faced and strategies to increase uptake. \u003cem\u003eFrontiers in Public Health\u003c/em\u003e, \u003cem\u003e10\u003c/em\u003e, 802947.\u003c/li\u003e\n \u003cli\u003eBitariho, G. K., Tuhebwe, D., Tigaiza, A., Nalugya, A., Ssekamatte, T., \u0026amp; Kiwanuka, S. N. (2023). Knowledge, perceptions and uptake of human papilloma virus vaccine among adolescent girls in Kampala, Uganda; a mixed-methods school-based study. \u003cem\u003eBMC pediatrics\u003c/em\u003e, \u003cem\u003e23\u003c/em\u003e(1), 368.\u003c/li\u003e\n \u003cli\u003eHolroyd, T. A., Yan, S. D., Srivastava, V., Srivastava, A., Wahl, B., Morgan, C., ... \u0026amp; Jennings, M. C. (2022). Designing a pro-equity HPV vaccine delivery program for girls who have dropped out of school: community perspectives from uttar pradesh, India. \u003cem\u003eHealth promotion practice\u003c/em\u003e, \u003cem\u003e23\u003c/em\u003e(6), 1039-1049.\u003c/li\u003e\n \u003cli\u003eAsgedom, Y. S., Kebede, T. M., Seifu, B. L., Mare, K. U., Asmare, Z. A., Asebe, H. A., ... \u0026amp; Kassie, G. A. (2024). Human papillomavirus vaccination uptake and determinant factors among adolescent schoolgirls in sub-Saharan Africa: A systematic review and meta-analysis. \u003cem\u003eHuman vaccines \u0026amp; immunotherapeutics\u003c/em\u003e, \u003cem\u003e20\u003c/em\u003e(1), 2326295.\u003c/li\u003e\n \u003cli\u003eYim, V. W. C., Wang, Q., Li, Y., Qin, C., Tang, W., Tang, S., ... \u0026amp; Wu, D. (2024). Between now and later: a mixed methods study of HPV vaccination delay among Chinese caregivers in urban Chengdu, China. BMC public health, 24(1), 183.\u003c/li\u003e\n \u003cli\u003eMbonigaba Rukarama Evarist. (2025). \u003cem\u003efactors associated with low uptake of human papilloma virus (HPV) vaccination series in adolescent girls in\u003c/em\u003e\u003cem\u003e\u0026nbsp;R\u003c/em\u003e\u003cem\u003eukiga district.\u003c/em\u003e (research dissertation-not published). Kabale University. research dissertation submitted in partial fulfilment for the requirements of the award of master\u0026rsquo;s degree of public health of Kabale University.july, 2025\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"HPV vaccination, low uptake, health facility factors, health system barriers, vaccine supply, cold chain, understaffing, health worker knowledge, rural health, Uganda","lastPublishedDoi":"10.21203/rs.3.rs-7597029/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7597029/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Cervical cancer, largely preventable through HPV vaccination, remains a significant public health burden in Uganda. Despite national immunization efforts, low completion rates for the two-dose HPV vaccine series persist, particularly in rural districts like Rukiga. This study aimed to investigate health facility-related factors contributing to the low uptake of the HPV vaccination series among adolescent girls in Rukiga District, Uganda.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e A cross-sectional study employing mixed methodologies was conducted with 292 adolescent girls and their caregivers in Rukiga District between September and November Multivariate logistic regression was utilized to identify health facility-level determinants of completing the two-dose HPV vaccine regimen. Additionally, qualitative data were gathered through in-depth interviews with 12 health workers and 10 Village Health Team members to explore operational and service delivery barriers to vaccine uptake.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e The study found that only 27.49% of eligible girls completed the two-dose HPV vaccination series. Significant health facility-related barriers included vaccine shortages and inadequate cold chain infrastructure (AOR = 1.75, 95% CI: 1.04-2.93, p = 0.004) and understaffing of healthcare workers (AOR = 1.97, 95% CI: 1.05-3.68, p = 0.006). Limited knowledge among health workers regarding the HPV vaccination schedule (AOR = 0.94, 95% CI: 0.70-1.24, p = 0.043) and the lack of clear government programs targeting out-of-school girls (AOR = 0.97, 95% CI: 0.73-1.29, p = 0.035) also contributed to reduced uptake. Qualitative findings further highlighted issues such as poor records management, inadequate community engagement by facilities, transportation challenges for vaccine delivery, and low staff motivation due to lack of incentives.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e Health facility limitations, particularly concerning vaccine supply, human resources, and operational efficiency, are critical impediments to completing the HPV vaccine series in Rukiga District. Addressing these systemic weaknesses through investments in cold chain infrastructure, increased staffing, enhanced health worker training, and robust outreach strategies is essential to improve vaccine coverage and reduce the burden of cervical cancer.\u003c/p\u003e","manuscriptTitle":"Bridging the Service Gap – Health Facility Challenges in HPV Vaccine Uptake in Rural Uganda","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-15 07:56:09","doi":"10.21203/rs.3.rs-7597029/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-11-19T08:14:36+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-12T14:35:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"221776311399234524702925586767908096584","date":"2025-11-11T10:48:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"205285418814170813881580988348587695757","date":"2025-11-06T16:39:51+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-21T19:37:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"176700711726415981022392101632039455706","date":"2025-09-26T16:14:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"332509387229867661858191516380293008624","date":"2025-09-23T08:21:00+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"98215374049044589910632910455314295990","date":"2025-09-21T17:52:13+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-21T04:40:14+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-09-17T12:47:35+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-15T08:22:19+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-15T08:21:18+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Women's Health","date":"2025-09-12T06:04:18+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f3c4450f-c747-4f20-82ab-e2b245db1b8d","owner":[],"postedDate":"September 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-14T13:08:33+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-15 07:56:09","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7597029","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7597029","identity":"rs-7597029","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}