Challenges to HPV Vaccination delivery at Rural Health Facilities Following Roll-Out of the Uganda National Program: A Cross-Sectional Study

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Bonner, Nicole E. Basta, Dawn M. Nederhoff, Katie Gravagna, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8216432/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objectives. National roll-out of new vaccines into the routine immunization program can present significant challenges at the time of initiation, especially in resource-limited settings. Evaluating various aspects of new vaccination programs and changes over time can provide insight, lessons learned, and opportunities for improvement. Our aim was to assess the frequency of health facility-reported HPV vaccination and vaccination documentation in a rural district in Northern Uganda. Methods. In this study, we evaluated the frequency of delivery of HPV vaccination activities at the health facility level before and during the expansion from school-based vaccination campaigns to integration of HPV vaccination into the routine immunization program using a cross-sectional study design. We conducted standardized interviews with health facility staff to evaluate HPV vaccination delivery and reviewed vaccination registries to determine the availability of HPV vaccination records at the health facility. Results. Although delivery of vaccinations increased over time, we found significant heterogeneity in the frequency of documentation of HPV vaccination activities over the study period, which presents opportunities to improve documentation to better track administration and evaluate program implementation. Conclusions. Our assessment provides critical insight into the challenges of HPV vaccination in the early stages of the national roll-out and can be used to evaluate current and future progress. Human Papillomavirus HPV Vaccine Routine Immunization Adolescents Uganda Health Facilities Vaccine Delivery Rural Health Introduction Cervical cancer continues to cause significant morbidity and mortality, as the fourth most common cause of cancer incidence and mortality among women worldwide. 1 An estimated 570,000 new cases of cervical cancer and 311,000 deaths from cervical cancer occurred in 2018. 1 Given that cervical cancer incidence and mortality rates in higher income countries have decreased in recent years, 2 low and middle income countries (LMICs) are now disproportionally affected by the disease and approximately 90% of worldwide cervical cancer deaths occur among those in LMICs. 3 Though mortality rates as low as < 2 per 100,000 women have been observed in high income countries, mortality rates have been reported as high as 28 per 100,000 women in LMICs. 4 Human Papillomavirus (HPV) infection can lead cervical cancer and many other types of cancer in both women and men. 3 Together, HPV-16 and HPV-18 are estimated to cause 71% of all cases of cervical cancer globally. 5 Reducing the risk of HPV infection in LMICs is a critical step towards reducing rates of cervical and other cancers. Ensuring access to HPV vaccination, which prevents against critically important cancer-causing HPV types, and ensuring high vaccination uptake when vaccines become available is vital for reducing the risk of acquiring HPV and the subsequent morbidity and mortality that infection can cause. 6 , 7 Improving coverage with HPV vaccination, which has been shown to be safe, effective, and cost-effective, is especially important in high-burden LMICs where cervical cancer screening programs are not as widely implemented. 6 , 7 The World Health Organization (WHO) recommended countries implement national HPV immunization programs with the primary goal of preventing cervical cancer and a secondary goal of preventing other disease caused by HPV. 8 Being vaccinated against HPV is vital for the prevention of HPV infection and for reducing the risk of cervical cancer. To prevent cervical cancer, the WHO recommended in 2017 that girls aged 9–14 years receive two doses of HPV vaccine six months apart and girls aged 15 years or older and girls who are immunocompromised receive three doses of HPV vaccine. 8 The WHO updated their recommendations in 2022 to support a one or two dose schedule for girls and women aged 9–20 years and a two dose schedule for women aged 21 or older. 9 Determining best strategies for delivering vaccinations is important for achieving and maintaining high rates of vaccination. Many countries have demonstrated success with HPV vaccination programs, which can include school-based, health center-based, and community-based combined with other health interventions. 10 In Nov. 2015, Uganda became the second country in Africa (after Rwanda) to launch nationwide HPV vaccination, transitioning from school-based campaigns into routine immunization, with vaccination activities taking place at health facilities and community outreaches including schools. 11 – 13 With support from GAVI, the Vaccine Alliance, the Government of Uganda recommended that the cohort of 10-year-old girls receive a two-dose HPV vaccine six months apart. Preparation for roll-out of the program included training sessions for health facility staff and village health workers who usually implement vaccination activities. 14 Even with extensive planning and training, national roll-out of new vaccination programs often face significant challenges during the initial phases of implementation, especially in resource-limited settings. 15 Lack of adequate finances, health care staff, infrastructure, and limitations to the cold chain can pose barriers. 16 Furthermore, HPV vaccination targets adolescents who are not typically the focus of other population-based health interventions and therefore can be hard to reach. 17 Although school-based vaccination campaigns have achieved high levels of coverage in many contexts, 10,18 the introduction of the HPV vaccine into the routine immunization program offers an opportunity for reaching eligible girls who do not attend school or do not attend school regularly enough to benefit from school-based intervention for both initial and subsequent doses of the vaccine. 15 In this study, our general aim was to evaluate the delivery of HPV vaccination activities at the health facility level in a rural district in Northern Uganda before and during the first 18 months after the integration of HPV vaccination into the routine immunization program. Specifically, we aimed to determine: 1) the frequency with which health facilities in rural Uganda participated in the HPV vaccination activities before and after integration into routine immunization program based on interviews with health care staff (health facility-reported vaccination activities) and 2) the availability of vaccination registry records documenting vaccinations during the study period (documented vaccination). Evaluating early efforts to implement new vaccination programs can provide important insight in potential implementation challenges or barriers and benchmarks for future assessments. Materials and Methods Study Design We conducted a cross sectional survey of health facilities (HFs) in rural Oyam district in northern Uganda in April 2017. We interviewed selected health facility staff and requested to see all available health facility HPV vaccination records and created digital scans of the paper records. All of Oyam’s 39 HFs at the time were eligible to participate in the study. Recruitment We selected a convenience sample of HFs in Oyam district to invite to participate. We aimed to recruit at least three HFs in subcounties with relatively few primary school learners and at least four HFs in subcounties with large number of learners during the time allocated for data collection. In this context, subcounty size was based on the total number of learners enrolled in public primary school in 2015 based on information provided by Oyam district education office (range among all subcounties: 3,861 to 15,990 learners). When the study team arrived at the designated health facility, one team member provided an introduction to the study to the health facility staff member who was in charge (henceforth referred to as the “staff member in-charge”). Once the staff member in-charge agreed to discuss the study, our data collection team joined the meeting and further explained the purpose of the visit and the survey, and asked if there were any questions or concerns, which were promptly addressed. The study team then conducted an informed consent process to the staff-member in-charge who expressed interest to participate followed by their verbal informed consent if they agreed to participate. This verbal informed consent was recorded by the data collector on the Health Facility Screening Form (HFSF) questionnaire. Survey Design Study staff orally administered the HFSF questionnaire to the staff in-charge in face-to-face interviews. The HFSF was a standardized form designed to document the staff-member in charge’s willingness to participate and to collect data including the health facility location (4 questions including Village, Parish, Sub-county), primary schools in the health facility catchment area (1 question), health facility participation in any HPV vaccination activities (2 questions), the dates (month/year) the health facility staff had participated in HPV vaccination activities (1 question), records of the vaccinations in the government issued HPV Vaccination Registry (1 question). Answers were recorded directly on the HFSF by the study staff. If the health facility conducted any HPV vaccination activities from 2015 to the time of interview in April 2017 and if they reported having recorded the vaccinations in the government-issued vaccination registry, study staff then asked for permission to see and to photograph the records from the registry(ies). If the health facility staff-member in-charge stated they kept records of the vaccination activities in some other form, study staff also asked permission to photograph those records. These records were scanned in duplicate using ScanbotPro (Available online: https://scanbot.io/)a s well as by using the camera function on the encrypted study tablets. After leaving the health facility, study staff digitized the HFSF and HPV vaccination records using REDCap electronic data capture software. 19 , 20 All data that were collected on the HFSF and data captured from the registries and other documents was double entered. Any discrepancies during data entry were resolved by the data entry staff by mutual agreement by comparing the data entry with the relevant source document. Vaccination activities and Registries The national HPV vaccine roll-out into the routine immunization program in Uganda was officially launched in November 2015. Prior to this date, vaccination was administered twice per year in October and April mainly during integrated Child Health Days Plus. Based on the interviews and the review of HPV vaccination records, we determined whether the health facility administered HPV vaccine prior to the nation-wide roll-out and whether they administered HPV vaccine after the national roll-out into the routine immunization program. Study staff asked for specific vaccination activities including the month and year of vaccine administration covering the period 2015 to April 2017. For each recorded date, the staff member in-charge reported whether vaccination records were kept in a government provided register (yes/no) and if the register was kept at the health facility (yes/no). Analysis All data was analyzed using Stata 14 statistical software. 21 To determine the proportion of HFs that reported undertaking any HPV vaccination activities (health facility-reported vaccination), we tabulated the total number of HPV vaccination activities, the dates (month/year) of the reported activities, and whether vaccination administration was documented. We then summarized: 1) the proportion of HFs that reported administering HPV vaccine prior to Nov. 2015, 2) the proportion of HFs that reported administering HPV vaccine at least once between Nov. 2015 and the time of the survey (April 2017), 3) the proportion of HFs that reported documenting HPV vaccination at least once in the government-issued HPV vaccination registries, and 4) the proportion of HFs that reported administering HPV vaccine in 6-month intervals prior to Nov. 2015 and post Nov. 2015 and how many consecutive times they did so. To determine the proportion of HFs that had documented HPV vaccination (documented vaccination), we tabulated the number of facilities that had HPV vaccination documentation available onsite for review. To assess the consistency between reported vaccination activities and the availability of corresponding HPV vaccination records, we summarized the proportion of HFs which had HPV vaccination activities recorded in their government issued vaccination registers matched the reported activities. Ethics Approval This study received ethical approval from Makerere University School of Medicine Research and Ethics Committee (SOMREC), the Uganda National Council for Science and Technology (UNCST), and the University of Minnesota Institutional Review Board (IRB), and was conducted in accordance with the Declaration of Helsinki. Results Our study team visited 17 of the 39 (43.6%) HFs in Oyam district and all (100%) staff-in-charge of those facilities agreed to participate. Ten HFs were located in subcounties with a large number of primary school learners and seven in subcounties with fewer number of learners. Of the 17 HFs, one was a hospital, one was a health center (HC) level IV, three were HC level III, and 12 were HC level II. A health facility’s designated level reflects the expected population in catchment area to be served, the expertise of staff available at the health facility and the level of care and services provided, with fewer services provided at facilities with lower-level designations. Staff at one HC II private-owned facility reported that they had not engaged in any vaccination activities during the study period. HFSF were completed for all HFs and images of available vaccination records were taken for this analysis. The health facility reports are summarized in Table 1 . Eleven 11/17 (65%) HFs administered the HPV vaccine before Nov. 2015, and 16/17 (94%) reported administering the HPV vaccine between 2015 and April 2017. At least one HPV vaccine registry was reported to be available at 12/17 (71%) HFs. Table 1 Health facility HPV vaccination participation summary statistics in 17 health facilities, Oyam district, Uganda, both prior to and following the nationwide introduction of HPV vaccine in Nov. 2015. Health Facility Self-Reported HPV Vaccination Efforts % (N) Reported any HPV vaccination prior to 2015 65% (11) Reported administering HPV vaccinations between April 2015-April 2017 94% (16) Reported documenting HPV vaccination in the vaccination register between April 2015-April 2017 71% (12) Reported HPV vaccination according to the recommended schedule, between November 2015 to April 2017 41% (7) Five of 17 (29%) HFs reported administering HPV vaccine in April 2015 and only 3/5 (60.0%) reported using a government-provided HPV vaccine register to document vaccinations, However, the registers from these facilities were not seen by the study team. In total, 13/17 (77%) HFs reported administering HPV vaccine by April 2017 out of which 10/13 (77%) reported using a government-provided register, and the register was available in those HFs. Vaccination activities were reported in months of April and October throughout the study period with no activities reported in intervening months as shown in Table 2 . Only 1/17 (6%) HF reported no HPV vaccination at all during this time period and 3/17 (18%) HFs reported five consecutive vaccinations cycles six months apart between April 2015 and April 2017. Four (24%) facilities reported that they were unable to administer a second dose of HPV vaccination six months after beginning to participate due to unforeseen circumstances. HF self-report of the availability of HPV vaccination documentation was more likely for vaccination activities that took place starting from 2016 onwards compared to the period before the national roll out of HPV vaccination into the routine EPI program in Nov. 2015. Actual documentation in the government-provided HPV vaccination registries improved over time. While no vaccination registry documentation was available for the 5 campaigns reported in April 2015 and the 8 reported October 2015, 10/13 (77%) HFs that participated in vaccination activities in April 2017 provided corresponding documentation (Table 2 ). Table 2 Health facility reported and documented HPV vaccination in 17 health facilities, Oyam district, Uganda, by month. Month/Year of HPV vaccination activities Health Facility Reported Participation in HPV Vaccination Activities among all Health Facilities Interviewed (N = 17) HPV Vaccinations Documented Reported that vaccination was delivered 1 Reported that vaccination was documented if vaccination was delivered 2 Reported that documentation was available at the time of survey if vaccination was delivered 3 Documentation of vaccination was verified in the vaccination register 4 May 2015 0 0 0 0 June 2015 0 0 0 0 July 2015 0 0 0 0 August 2015 0 0 0 0 September 2015 0 0 0 0 Oct/Nov 2015 47% (8) 25% (2) 0% (0) 0% (0/8) December 2015 0 0 0 0 January 2016 0 0 0 0 February 2016 0 0 0 0 March 2016 0 0 0 0 Apr 2016 77% (13) 77% (10) 69% (9) 62% (8/13) May 2016 0 0 0 0 June 2016 0 0 0 0 July 2016 0 0 0 0 August 2016 0 0 0 0 September 2016 0 0 0 0 Oct/Nov 2016 82% (14) 79% (11) 79% (11) 50% (7/14) December 2016 0 0 0 0 January 2017 0 0 0 0 February 2017 0 0 0 0 March 2017 0 0 0 0 Apr 2017 77% (13) 77% (10) 77% (10) 77% (10/13) 1 Health facility staff reported that vaccination activities took place in the given month. 2 Health facility staff reported that vaccination activities were recorded in HPV vaccination registers in the given month. 3 Health facility staff reported that vaccination activities were recorded in HPV vaccination registers in the given month and that these registers were available at the facility. 4 Health facility staff provided the vaccination registries for verification of documentation of vaccination activities in a given month. Discussion We examined the frequency of health facility HPV vaccination activities in rural Northern Uganda just prior to and in the 18 months after national roll-out into immunization program. We found that both self-reported and documented health facility participation in HPV vaccination improved over the course of 18 months following the national launch of HPV vaccination into the routine immunization program. We found that after initial participation in HPV vaccination campaigns, some HFs reported missing subsequent vaccination opportunities, suggesting the need for early identification and response to barriers to HPV vaccination implementation to ensure consistent HPV vaccination delivery. Health facility self-reports on participation in HPV vaccination were generally accurate when compared with registry records provided, but confirmation was not possible in over half of cases given that documentation was not available at the time of the survey. Studies have shown that routine and outreach vaccination activities in schools are an effective and efficient way to deliver vaccines in LMICs. 10 , 18 In our study, we observed increases over time in both the number of HFs that reported participating in HPV vaccination activities and the number of vaccination activities that were documented in a government-issued vaccination register. Thus, HFs improved their reach, leading to more vaccination activities and improved documentation in government-provided registries, which guaranteed that children initially vaccinated could be followed up for administration of the second dose of HPV vaccine. The discrepancies between self-report of vaccine administration, documentation of vaccine administration, and document availability are concerning and reflect early challenges the vaccination program faced. Increased availability of records and data storage would help planning and decision making at health facility level. With a record of vaccination activities available at the health facility, it will be possible to assess where outreach activities, including school-based immunization are being conducted, and which girls received a dose, and when they are due to complete the vaccination series whether through school-based or health facility-based vaccination activities. Such records could be used to track the proportion of girls missing out on the second dose of HPV vaccine and the proportion of eligible girls who have missed out on HPV vaccination entirely. Public Health Implications An early evaluation of newly launched vaccination roll-out can provide insight into program execution, which can in turn inform stakeholders about the process and help to inform interventions that may help improve vaccination delivery. Our results suggest that vaccination was not consistently delivered or documented, which could imply that eligible girls in those jurisdictions could have missed out on HPV vaccination. Secondly, the absence of self-reports and documentation of vaccination activities outside of April and October 18 months after vaccination integration in routine immunization program seems to imply lack of transition from campaigns to routine vaccination delivery. Further studies that examine the barriers that HFs faced in delivering routine HPV vaccinations are critical to support ongoing HPV vaccination efforts and ensure access to HPV vaccination for all eligible adolescents. Our study is one of the first post-national roll out vaccination studies in a rural district conducted to provide insight of early challenges and potential opportunities of implementing HPV vaccination activities at health facility level. Our analysis of findings at the health-facility level provides evidence for opportunities to ensure that HPV vaccination is delivered consistently and to address barriers to delivery that result in missed vaccination opportunities. Our study has several limitations that should be considered. First, since we selected a convenience sample of HFs in one rural district in Uganda, these results may not be representative of other districts throughout the country or other countries or contexts. However, we undertook extensive efforts to survey nearly half (17 of the 39) HFs in the district and included HFs at all administrative levels to gain a better understanding of early challenges facing HPV vaccination efforts over a range of resource-availability. Second, we conducted the survey in the later part of April 2017 and asked HFs to report whether they had undertaken any HPV vaccination activities during the month of April 2017. Because of the timing of data collection, it is possible that HFs, which had not initiated vaccination by the time of the survey did ultimately begin during the last days of the month of April. Such a delayed start would not have been captured in our analysis. Despite these limitations due to logistical constraints, our assessment provides critical baseline insight into the initial challenges of HPV vaccination roll-out and can be used to evaluate current and future progress. Conclusion In conclusion, we investigated the degree to which health facilities in rural Uganda implemented HPV vaccination in the initial months of the nationwide HPV vaccination roll-out into the routine EPI program. We found that HPV vaccination activities increased over this time, and that the frequency of vaccination record keeping practices improved, as well. Continuing to improve the frequency of vaccination documentation will be critical to future evaluation of HPV vaccine uptake and series completion. Based on discussions with health facility staff, additional resources, training, and support could improve data management and record-keeping at the level of local health facilities and reduce barriers to launching vaccination on the recommended schedule. Declarations Declaration of conflicting interest The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding statement: Funding for this research was provided by the University of Minnesota Academic Health Center Seed Grant (PIs CB and NEB) and the University of Minnesota Grand Challenges Exploratory Grant (PIs: CB and NEB). NEB is also supported by a Canada Research Chair (Tier 2) in Infectious Disease Prevention. Author Contribution Authors contributing to - The conception and design: All; Data Collection: CB, KB, DN; Analysis: KB; Interpretation of the data: All; Drafting of the paper: KB, DN, NEB; Revising it critically for intellectual content: All; All authors provided final approval of this version to be published and agree to be accountable for all aspects of this work. 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15:45:44","extension":"html","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":85057,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8216432/v1/b379fe624a40c09da723bbf5.html"},{"id":99679659,"identity":"d11855e0-3f9f-4914-9fe9-69c4105ff175","added_by":"auto","created_at":"2026-01-07 08:40:57","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":672357,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8216432/v1/80677c46-98f0-4b47-a79a-c339aa198b6a.pdf"},{"id":97870640,"identity":"e52aafe4-b518-4a4f-ada7-d2543bcd0d60","added_by":"auto","created_at":"2025-12-10 10:19:59","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":31051,"visible":true,"origin":"","legend":"","description":"","filename":"STROBEchecklistcrosssectional.docx","url":"https://assets-eu.researchsquare.com/files/rs-8216432/v1/e1ebc1dac9c672376e409482.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Challenges to HPV Vaccination delivery at Rural Health Facilities Following Roll-Out of the Uganda National Program: A Cross-Sectional Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCervical cancer continues to cause significant morbidity and mortality, as the fourth most common cause of cancer incidence and mortality among women worldwide.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e An estimated 570,000 new cases of cervical cancer and 311,000 deaths from cervical cancer occurred in 2018.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Given that cervical cancer incidence and mortality rates in higher income countries have decreased in recent years,\u003csup\u003e2\u003c/sup\u003e low and middle income countries (LMICs) are now disproportionally affected by the disease and approximately 90% of worldwide cervical cancer deaths occur among those in LMICs.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e Though mortality rates as low as \u0026lt;\u0026thinsp;2 per 100,000 women have been observed in high income countries, mortality rates have been reported as high as 28 per 100,000 women in LMICs.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eHuman Papillomavirus (HPV) infection can lead cervical cancer and many other types of cancer in both women and men.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e Together, HPV-16 and HPV-18 are estimated to cause 71% of all cases of cervical cancer globally.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eReducing the risk of HPV infection in LMICs is a critical step towards reducing rates of cervical and other cancers. Ensuring access to HPV vaccination, which prevents against critically important cancer-causing HPV types, and ensuring high vaccination uptake when vaccines become available is vital for reducing the risk of acquiring HPV and the subsequent morbidity and mortality that infection can cause.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e Improving coverage with HPV vaccination, which has been shown to be safe, effective, and cost-effective, is especially important in high-burden LMICs where cervical cancer screening programs are not as widely implemented.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eThe World Health Organization (WHO) recommended countries implement national HPV immunization programs with the primary goal of preventing cervical cancer and a secondary goal of preventing other disease caused by HPV.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e Being vaccinated against HPV is vital for the prevention of HPV infection and for reducing the risk of cervical cancer. To prevent cervical cancer, the WHO recommended in 2017 that girls aged 9\u0026ndash;14 years receive two doses of HPV vaccine six months apart and girls aged 15 years or older and girls who are immunocompromised receive three doses of HPV vaccine.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e The WHO updated their recommendations in 2022 to support a one or two dose schedule for girls and women aged 9\u0026ndash;20 years and a two dose schedule for women aged 21 or older.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eDetermining best strategies for delivering vaccinations is important for achieving and maintaining high rates of vaccination. Many countries have demonstrated success with HPV vaccination programs, which can include school-based, health center-based, and community-based combined with other health interventions.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e In Nov. 2015, Uganda became the second country in Africa (after Rwanda) to launch nationwide HPV vaccination, transitioning from school-based campaigns into routine immunization, with vaccination activities taking place at health facilities and community outreaches including schools.\u003csup\u003e\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e With support from GAVI, the Vaccine Alliance, the Government of Uganda recommended that the cohort of 10-year-old girls receive a two-dose HPV vaccine six months apart.\u003c/p\u003e\u003cp\u003ePreparation for roll-out of the program included training sessions for health facility staff and village health workers who usually implement vaccination activities.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eEven with extensive planning and training, national roll-out of new vaccination programs often face significant challenges during the initial phases of implementation, especially in resource-limited settings.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e Lack of adequate finances, health care staff, infrastructure, and limitations to the cold chain can pose barriers.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e Furthermore, HPV vaccination targets adolescents who are not typically the focus of other population-based health interventions and therefore can be hard to reach.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e Although school-based vaccination campaigns have achieved high levels of coverage in many contexts,\u003csup\u003e10,18\u003c/sup\u003e the introduction of the HPV vaccine into the routine immunization program offers an opportunity for reaching eligible girls who do not attend school or do not attend school regularly enough to benefit from school-based intervention for both initial and subsequent doses of the vaccine.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eIn this study, our general aim was to evaluate the delivery of HPV vaccination activities at the health facility level in a rural district in Northern Uganda before and during the first 18 months after the integration of HPV vaccination into the routine immunization program. Specifically, we aimed to determine: 1) the frequency with which health facilities in rural Uganda participated in the HPV vaccination activities before and after integration into routine immunization program based on interviews with health care staff (health facility-reported vaccination activities) and 2) the availability of vaccination registry records documenting vaccinations during the study period (documented vaccination). Evaluating early efforts to implement new vaccination programs can provide important insight in potential implementation challenges or barriers and benchmarks for future assessments.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Design\u003c/h2\u003e\u003cp\u003eWe conducted a cross sectional survey of health facilities (HFs) in rural Oyam district in northern Uganda in April 2017. We interviewed selected health facility staff and requested to see all available health facility HPV vaccination records and created digital scans of the paper records. All of Oyam\u0026rsquo;s 39 HFs at the time were eligible to participate in the study.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eRecruitment\u003c/h3\u003e\n\u003cp\u003eWe selected a convenience sample of HFs in Oyam district to invite to participate. We aimed to recruit at least three HFs in subcounties with relatively few primary school learners and at least four HFs in subcounties with large number of learners during the time allocated for data collection. In this context, subcounty size was based on the total number of learners enrolled in public primary school in 2015 based on information provided by Oyam district education office (range among all subcounties: 3,861 to 15,990 learners). When the study team arrived at the designated health facility, one team member provided an introduction to the study to the health facility staff member who was in charge (henceforth referred to as the \u0026ldquo;staff member in-charge\u0026rdquo;). Once the staff member in-charge agreed to discuss the study, our data collection team joined the meeting and further explained the purpose of the visit and the survey, and asked if there were any questions or concerns, which were promptly addressed. The study team then conducted an informed consent process to the staff-member in-charge who expressed interest to participate followed by their verbal informed consent if they agreed to participate. This verbal informed consent was recorded by the data collector on the Health Facility Screening Form (HFSF) questionnaire.\u003c/p\u003e\n\u003ch3\u003eSurvey Design\u003c/h3\u003e\n\u003cp\u003eStudy staff orally administered the HFSF questionnaire to the staff in-charge in face-to-face interviews. The HFSF was a standardized form designed to document the staff-member in charge\u0026rsquo;s willingness to participate and to collect data including the health facility location (4 questions including Village, Parish, Sub-county), primary schools in the health facility catchment area (1 question), health facility participation in any HPV vaccination activities (2 questions), the dates (month/year) the health facility staff had participated in HPV vaccination activities (1 question), records of the vaccinations in the government issued HPV Vaccination Registry (1 question). Answers were recorded directly on the HFSF by the study staff.\u003c/p\u003e\u003cp\u003eIf the health facility conducted any HPV vaccination activities from 2015 to the time of interview in April 2017 and if they reported having recorded the vaccinations in the government-issued vaccination registry, study staff then asked for permission to see and to photograph the records from the registry(ies). If the health facility staff-member in-charge stated they kept records of the vaccination activities in some other form, study staff also asked permission to photograph those records. These records were scanned in duplicate using ScanbotPro (Available online: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://scanbot.io/)a\u003c/span\u003e\u003cspan address=\"https://scanbot.io/)a\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003es well as by using the camera function on the encrypted study tablets. After leaving the health facility, study staff digitized the HFSF and HPV vaccination records using REDCap electronic data capture software.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e All data that were collected on the HFSF and data captured from the registries and other documents was double entered. Any discrepancies during data entry were resolved by the data entry staff by mutual agreement by comparing the data entry with the relevant source document.\u003c/p\u003e\n\u003ch3\u003eVaccination activities and Registries\u003c/h3\u003e\n\u003cp\u003eThe national HPV vaccine roll-out into the routine immunization program in Uganda was officially launched in November 2015. Prior to this date, vaccination was administered twice per year in October and April mainly during integrated Child Health Days Plus. Based on the interviews and the review of HPV vaccination records, we determined whether the health facility administered HPV vaccine prior to the nation-wide roll-out and whether they administered HPV vaccine after the national roll-out into the routine immunization program. Study staff asked for specific vaccination activities including the month and year of vaccine administration covering the period 2015 to April 2017. For each recorded date, the staff member in-charge reported whether vaccination records were kept in a government provided register (yes/no) and if the register was kept at the health facility (yes/no).\u003c/p\u003e\n\u003ch3\u003eAnalysis\u003c/h3\u003e\n\u003cp\u003eAll data was analyzed using Stata 14 statistical software.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eTo determine the proportion of HFs that reported undertaking any HPV vaccination activities (health facility-reported vaccination), we tabulated the total number of HPV vaccination activities, the dates (month/year) of the reported activities, and whether vaccination administration was documented. We then summarized: 1) the proportion of HFs that reported administering HPV vaccine prior to Nov. 2015, 2) the proportion of HFs that reported administering HPV vaccine at least once between Nov. 2015 and the time of the survey (April 2017), 3) the proportion of HFs that reported documenting HPV vaccination at least once in the government-issued HPV vaccination registries, and 4) the proportion of HFs that reported administering HPV vaccine in 6-month intervals prior to Nov. 2015 and post Nov. 2015 and how many consecutive times they did so.\u003c/p\u003e\u003cp\u003eTo determine the proportion of HFs that had documented HPV vaccination (documented vaccination), we tabulated the number of facilities that had HPV vaccination documentation available onsite for review.\u003c/p\u003e\u003cp\u003eTo assess the consistency between reported vaccination activities and the availability of corresponding HPV vaccination records, we summarized the proportion of HFs which had HPV vaccination activities recorded in their government issued vaccination registers matched the reported activities.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eEthics Approval\u003c/h2\u003e\u003cp\u003eThis study received ethical approval from Makerere University School of Medicine Research and Ethics Committee (SOMREC), the Uganda National Council for Science and Technology (UNCST), and the University of Minnesota Institutional Review Board (IRB), and was conducted in accordance with the Declaration of Helsinki.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eOur study team visited 17 of the 39 (43.6%) HFs in Oyam district and all (100%) staff-in-charge of those facilities agreed to participate. Ten HFs were located in subcounties with a large number of primary school learners and seven in subcounties with fewer number of learners. Of the 17 HFs, one was a hospital, one was a health center (HC) level IV, three were HC level III, and 12 were HC level II. A health facility\u0026rsquo;s designated level reflects the expected population in catchment area to be served, the expertise of staff available at the health facility and the level of care and services provided, with fewer services provided at facilities with lower-level designations. Staff at one HC II private-owned facility reported that they had not engaged in any vaccination activities during the study period. HFSF were completed for all HFs and images of available vaccination records were taken for this analysis.\u003c/p\u003e\u003cp\u003eThe health facility reports are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Eleven 11/17 (65%) HFs administered the HPV vaccine before Nov. 2015, and 16/17 (94%) reported administering the HPV vaccine between 2015 and April 2017. At least one HPV vaccine registry was reported to be available at 12/17 (71%) HFs.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eHealth facility HPV vaccination participation summary statistics in 17 health facilities, Oyam district, Uganda, both prior to and following the nationwide introduction of HPV vaccine in Nov. 2015.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHealth Facility Self-Reported HPV Vaccination Efforts\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e% (N)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eReported any HPV vaccination prior to 2015\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e65% (11)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eReported administering HPV vaccinations between April 2015-April 2017\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e94% (16)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eReported documenting HPV vaccination in the vaccination register between April 2015-April 2017\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e71% (12)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eReported HPV vaccination according to the recommended schedule, between November 2015 to April 2017\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e41% (7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eFive of 17 (29%) HFs reported administering HPV vaccine in April 2015 and only 3/5 (60.0%) reported using a government-provided HPV vaccine register to document vaccinations, However, the registers from these facilities were not seen by the study team. In total, 13/17 (77%) HFs reported administering HPV vaccine by April 2017 out of which 10/13 (77%) reported using a government-provided register, and the register was available in those HFs.\u003c/p\u003e\u003cp\u003eVaccination activities were reported in months of April and October throughout the study period with no activities reported in intervening months as shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Only 1/17 (6%) HF reported no HPV vaccination at all during this time period and 3/17 (18%) HFs reported five consecutive vaccinations cycles six months apart between April 2015 and April 2017. Four (24%) facilities reported that they were unable to administer a second dose of HPV vaccination six months after beginning to participate due to unforeseen circumstances. HF self-report of the availability of HPV vaccination documentation was more likely for vaccination activities that took place starting from 2016 onwards compared to the period before the national roll out of HPV vaccination into the routine EPI program in Nov. 2015. Actual documentation in the government-provided HPV vaccination registries improved over time. While no vaccination registry documentation was available for the 5 campaigns reported in April 2015 and the 8 reported October 2015, 10/13 (77%) HFs that participated in vaccination activities in April 2017 provided corresponding documentation (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eHealth facility reported and documented HPV vaccination in 17 health facilities, Oyam district, Uganda, by month.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMonth/Year of HPV vaccination activities\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003eHealth Facility Reported Participation in HPV Vaccination Activities among all Health Facilities Interviewed (N\u0026thinsp;=\u0026thinsp;17)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eHPV Vaccinations Documented\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eReported that vaccination was delivered\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eReported that vaccination was documented if vaccination was delivered\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eReported that documentation was available at the time of survey if vaccination was delivered\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eDocumentation of vaccination was verified in the vaccination register\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMay 2015\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eJune 2015\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eJuly 2015\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAugust 2015\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSeptember 2015\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOct/Nov 2015\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e47% (8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25% (2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0% (0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0% (0/8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDecember 2015\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eJanuary 2016\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFebruary 2016\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMarch 2016\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eApr 2016\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e77% (13)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e77% (10)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e69% (9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e62% (8/13)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMay 2016\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eJune 2016\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eJuly 2016\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAugust 2016\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSeptember 2016\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOct/Nov 2016\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e82% (14)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e79% (11)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e79% (11)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e50% (7/14)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDecember 2016\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eJanuary 2017\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFebruary 2017\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMarch 2017\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eApr 2017\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e77% (13)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e77% (10)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e77% (10)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e77% (10/13)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003e\u003csup\u003e1\u003c/sup\u003eHealth facility staff reported that vaccination activities took place in the given month.\u003c/p\u003e\u003cp\u003e\u003csup\u003e2\u003c/sup\u003eHealth facility staff reported that vaccination activities were recorded in HPV vaccination registers in the given month.\u003c/p\u003e\u003cp\u003e\u003csup\u003e3\u003c/sup\u003eHealth facility staff reported that vaccination activities were recorded in HPV vaccination registers in the given month and that these registers were available at the facility.\u003c/p\u003e\u003cp\u003e\u003csup\u003e4\u003c/sup\u003eHealth facility staff provided the vaccination registries for verification of documentation of vaccination activities in a given month.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eWe examined the frequency of health facility HPV vaccination activities in rural Northern Uganda just prior to and in the 18 months after national roll-out into immunization program. We found that both self-reported and documented health facility participation in HPV vaccination improved over the course of 18 months following the national launch of HPV vaccination into the routine immunization program.\u003c/p\u003e\u003cp\u003eWe found that after initial participation in HPV vaccination campaigns, some HFs reported missing subsequent vaccination opportunities, suggesting the need for early identification and response to barriers to HPV vaccination implementation to ensure consistent HPV vaccination delivery. Health facility self-reports on participation in HPV vaccination were generally accurate when compared with registry records provided, but confirmation was not possible in over half of cases given that documentation was not available at the time of the survey.\u003c/p\u003e\u003cp\u003eStudies have shown that routine and outreach vaccination activities in schools are an effective and efficient way to deliver vaccines in LMICs.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e In our study, we observed increases over time in both the number of HFs that reported participating in HPV vaccination activities and the number of vaccination activities that were documented in a government-issued vaccination register. Thus, HFs improved their reach, leading to more vaccination activities and improved documentation in government-provided registries, which guaranteed that children initially vaccinated could be followed up for administration of the second dose of HPV vaccine.\u003c/p\u003e\u003cp\u003eThe discrepancies between self-report of vaccine administration, documentation of vaccine administration, and document availability are concerning and reflect early challenges the vaccination program faced. Increased availability of records and data storage would help planning and decision making at health facility level. With a record of vaccination activities available at the health facility, it will be possible to assess where outreach activities, including school-based immunization are being conducted, and which girls received a dose, and when they are due to complete the vaccination series whether through school-based or health facility-based vaccination activities. Such records could be used to track the proportion of girls missing out on the second dose of HPV vaccine and the proportion of eligible girls who have missed out on HPV vaccination entirely.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003ePublic Health Implications\u003c/h2\u003e\u003cp\u003eAn early evaluation of newly launched vaccination roll-out can provide insight into program execution, which can in turn inform stakeholders about the process and help to inform interventions that may help improve vaccination delivery. Our results suggest that vaccination was not consistently delivered or documented, which could imply that eligible girls in those jurisdictions could have missed out on HPV vaccination. Secondly, the absence of self-reports and documentation of vaccination activities outside of April and October 18 months after vaccination integration in routine immunization program seems to imply lack of transition from campaigns to routine vaccination delivery. Further studies that examine the barriers that HFs faced in delivering routine HPV vaccinations are critical to support ongoing HPV vaccination efforts and ensure access to HPV vaccination for all eligible adolescents.\u003c/p\u003e\u003cp\u003eOur study is one of the first post-national roll out vaccination studies in a rural district conducted to provide insight of early challenges and potential opportunities of implementing HPV vaccination activities at health facility level. Our analysis of findings at the health-facility level provides evidence for opportunities to ensure that HPV vaccination is delivered consistently and to address barriers to delivery that result in missed vaccination opportunities.\u003c/p\u003e\u003cp\u003eOur study has several limitations that should be considered. First, since we selected a convenience sample of HFs in one rural district in Uganda, these results may not be representative of other districts throughout the country or other countries or contexts. However, we undertook extensive efforts to survey nearly half (17 of the 39) HFs in the district and included HFs at all administrative levels to gain a better understanding of early challenges facing HPV vaccination efforts over a range of resource-availability. Second, we conducted the survey in the later part of April 2017 and asked HFs to report whether they had undertaken any HPV vaccination activities during the month of April 2017. Because of the timing of data collection, it is possible that HFs, which had not initiated vaccination by the time of the survey did ultimately begin during the last days of the month of April. Such a delayed start would not have been captured in our analysis. Despite these limitations due to logistical constraints, our assessment provides critical baseline insight into the initial challenges of HPV vaccination roll-out and can be used to evaluate current and future progress.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, we investigated the degree to which health facilities in rural Uganda implemented HPV vaccination in the initial months of the nationwide HPV vaccination roll-out into the routine EPI program. We found that HPV vaccination activities increased over this time, and that the frequency of vaccination record keeping practices improved, as well. Continuing to improve the frequency of vaccination documentation will be critical to future evaluation of HPV vaccine uptake and series completion. Based on discussions with health facility staff, additional resources, training, and support could improve data management and record-keeping at the level of local health facilities and reduce barriers to launching vaccination on the recommended schedule.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eDeclaration of conflicting interest\u003c/h2\u003e\u003cp\u003eThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.\u003c/p\u003e\u003ch2\u003eFunding statement:\u003c/h2\u003e\u003cp\u003eFunding for this research was provided by the University of Minnesota Academic Health Center Seed Grant (PIs CB and NEB) and the University of Minnesota Grand Challenges Exploratory Grant (PIs: CB and NEB). NEB is also supported by a Canada Research Chair (Tier 2) in Infectious Disease Prevention.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAuthors contributing to - The conception and design: All; Data Collection: CB, KB, DN; Analysis: KB; Interpretation of the data: All; Drafting of the paper: KB, DN, NEB; Revising it critically for intellectual content: All; All authors provided final approval of this version to be published and agree to be accountable for all aspects of this work.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eArbyn M, et al. Estimates of incidence and mortality of cervical cancer in 2018: a worldwide analysis. 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StataCorp LP: College Station, TX; 2015.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Human Papillomavirus, HPV Vaccine, Routine Immunization, Adolescents, Uganda, Health Facilities, Vaccine Delivery, Rural Health","lastPublishedDoi":"10.21203/rs.3.rs-8216432/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8216432/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjectives.\u003c/h2\u003e\u003cp\u003eNational roll-out of new vaccines into the routine immunization program can present significant challenges at the time of initiation, especially in resource-limited settings. Evaluating various aspects of new vaccination programs and changes over time can provide insight, lessons learned, and opportunities for improvement. Our aim was to assess the frequency of health facility-reported HPV vaccination and vaccination documentation in a rural district in Northern Uganda.\u003c/p\u003e\u003ch2\u003eMethods.\u003c/h2\u003e\u003cp\u003eIn this study, we evaluated the frequency of delivery of HPV vaccination activities at the health facility level before and during the expansion from school-based vaccination campaigns to integration of HPV vaccination into the routine immunization program using a cross-sectional study design. We conducted standardized interviews with health facility staff to evaluate HPV vaccination delivery and reviewed vaccination registries to determine the availability of HPV vaccination records at the health facility.\u003c/p\u003e\u003ch2\u003eResults.\u003c/h2\u003e\u003cp\u003eAlthough delivery of vaccinations increased over time, we found significant heterogeneity in the frequency of documentation of HPV vaccination activities over the study period, which presents opportunities to improve documentation to better track administration and evaluate program implementation.\u003c/p\u003e\u003ch2\u003eConclusions.\u003c/h2\u003e\u003cp\u003eOur assessment provides critical insight into the challenges of HPV vaccination in the early stages of the national roll-out and can be used to evaluate current and future progress.\u003c/p\u003e","manuscriptTitle":"Challenges to HPV Vaccination delivery at Rural Health Facilities Following Roll-Out of the Uganda National Program: A Cross-Sectional Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-10 10:19:54","doi":"10.21203/rs.3.rs-8216432/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3683e7d4-b46a-4450-8895-81f230c66208","owner":[],"postedDate":"December 10th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-01-07T08:40:22+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-10 10:19:54","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8216432","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8216432","identity":"rs-8216432","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}