Examining barriers and facilitators of HPV vaccination in Nigeria, in the context of an innovative delivery model: a mixed-methods study

Abstract

Background More than 80% of cervical cancer cases diagnosed globally are in low- income and middle- income countries. In sub- Saharan Africa, where treatment facilities are widely unavailable, it is a leading cause of cancer deaths in women. Human papillomavirus (HPV) vaccination, which is known to prevent almost 90% of cases of cervical cancer, has low uptake in this region, and little is known about the behaviour of those who have been offered the HPV vaccine. This knowledge is critical to guide policy- makers in sub- Saharan Africa on how best to roll out the vaccine and ensure successful and sustainable HPV vaccination programmes. Methods To better understand uptake of the HPV vaccine among schoolgirls in Nigeria, we designed a mixed- methods convergent study, with a case–control quantitative arm that recruited caregivers of adolescent schoolgirls as cases (those who accepted vaccination) and controls (those who did not accept vaccination). For the qualitative study, we conducted 10 focus group discussions with of caregivers and 6 in- depth interviews with school administrators, vaccination sponsors and policy- makers. Results Those with high awareness of HPV vaccination had three times the odds of uptake (adjusted OR (aOR) 2.6, 95% CI 1.54 to 4.31, p=0.002). Giving HPV vaccines in school was also associated with uptake (aOR 3.1, 95% CI 1.54 to 6.43, p=0.002). Being offered free HPV vaccination was significant in the bivariate analysis (aOR 1.67, 95% CI 1.03 to 2.70, p=0.039) but was marginally significant in the multivariate analysis (aOR 0.63, 95% CI 0.37 to 1.06, p=0.086). Qualitative themes supported these findings, demonstrating that effective awareness and convenience of vaccination could encourage uptake. Key barriers to uptake included lack of affordability and limited availability of vaccines. Conclusions Effective awareness, administering HPV vaccines in school and subsidising HPV vaccination costs can improve uptake.