A total of 407 respondents were interviewed from the calculated sample size of 432 giving a non-response rate of 9%.
Socio-demographic characteristics of the respondents
Table 1 shows the baseline characteristics of the respondents; the mean age was 11.8 ± 1.8 years with a minimum age of 9 years and a maximum of 15 years. 75% (306/407) of the respondents lived in rural areas. The care takers of the adolescents were mostly married (73.5%) with half of them having attained up to primary level of education (50.1%). Most of respondents were of the Gishu tribe (71.3%), and more than two thirds were of Muslim faith (41.5%). Most (71%) of the respondents lived approximately 1km to 3km from a health facility.
Initiation of the HPV vaccine
Figure 1 shows the total number of adolescents interviewed, 49% (200/407) had initiated the vaccination, of these, adolescents that had initiated the HPV vaccine, 13.8% (56/407) had received both doses and thus completed the vaccination. See figure 1.
Table 2 shows the main reasons for not receiving the vaccine. The total number of respondents was 348 because it included only those who had either received one dose or none. Lack of awareness was the main reason given by 45% (182/348) of the adolescents. While some respondents mentioned that they were not aware about the HPV vaccine, some were not aware of the number of doses that they must receive and others were not aware of the schedule or interval of the vaccines. Less than 2% (6/348) of the respondents mentioned unfriendly health workers as a major reason for failure to obtain the vaccine, while four percent 4% (14/348) of the respondents who had received one dose were aware that they were due for a second dose. Other reasons for not vaccinating include reluctance to vaccinate, being afraid of vaccines, and myths about the vaccines.
Factors associated with uptake of the HPV vaccine
Table 3 shows that the prevalence of uptake was two times higher among the age group of eleven to twelve years (PR 2.1, 95% CI 1.0-4.4) compared to those who are nine to ten years. It was also twice higher among the Banyole ethnic group (UPR2.2, 95% CI, 1.18- 4.04) compared to the Bagishu, it was also six times higher among adolescents whose care takers were business women (unadjusted PRR 5.9, 95% CI 2.0- 16.9) compared to those who were housewives
Uptake for the vaccine was also twice higher among those who had received other childhood vaccines (UPR 1.8, 95% CI 1.05-3.01), and seven times higher among those who obtained HPV vaccine from outreach clinics (UPR 7.4, 95% CI 3.6-15.15). Additionally, uptake was eleven times higher among those who received an explanation on the side effects of the HPV vaccine (UPR 10.6, 95% CI 5.5-20.57), six times higher among those who got the vaccines alongside other services (unadjusted PRR 5.8, 95%CI 3.4-9.7), seven times higher among adolescents who had many options from where to receive HPV vaccine (unadjusted PRR 7.1, 95% CI 3.5-14.18) and three times higher among those with knowledge of where to report side effects (UPR 3.0 95% CI 1.7-5.1).
Table 4; shows the multivariable analysis, after adjusting for possible confounders, the prevalence of uptake of the HPV vaccine was two and a half times higher among girls who had received the vaccine from an outreach clinic APR 2.6,95% CI: 1.2-5.9) compared to those who obtained from static sites. It was also three times higher among those who received an explanation for possible side effects (APR 2.7, 95% CI 1.1-6.4) compared to those who didn’t get an explanation. Prevalence was also twice higher among adolescents who received vaccines together with other services (APR 2.3, 95% CI 1.1-4.6) and four times more among adolescents who had many options from where to receive the HPV vaccine (APR 3.6, 95% CI 1.6-8.1) after controlling for all the other significant variables at bivariate analysis. See table below
Barriers to service delivery
In the study, the major barriers to service delivery from the key informant interviews included low financing, myths about the vaccine, unclear communication on the target for the vaccine’s coverage and transport challenges to reach the adolescents in the community. Funding for immunization activities was previously provided by other organizations that supplemented the Primary Health Care (PHC) funds but this was not happening at the time of the study. This is affirmed by one key informant who states that;
“Previously, GAVI was supplementing the PHC Funds but in the last financial year, it has been hard to manage and I am sure that some facilities have not been able to conduct outreaches in both the schools and the community”
(Key informant 2, DHT)
Some key informants revealed that private schools and private health facilities are not given the HPV vaccine and this creates inequity in access for those who prefer to utilize private health facilities for receipt of the vaccine and girls in private schools.
“We supply the vaccine to the public and private not for profit health facilities, we are not giving the private clinics, this is because many of them are not equipped with the cold chain and they do not report to us.”
(Key Informant 1, DHT)
“We give out this vaccine to government schools only, the private schools don’t benefit because they have to obtain parental consent for their pupils to get it. In the Government schools, the school authority gives the consent”
(Key Informant 3 health facility in-charge)
Facilitators to service delivery
HPV vaccine delivery has been made easier through the school-based delivery approach because the target group was clear but there was confusion as to whether to vaccinate those in primary five since the target class is primary four. With the school-based approach, health facilities have been able to liaise with schools to make it easy for the adolescents to receive HPV vaccine as stated by one key informant below
“Health facilities liaise with the schools so that arrangements are made for the HPV vaccination, for example they set aside a classroom where the equipment can be placed so that the vaccination can take place”
(Key Informant 2, Healthy facility in-charge)
Barriers for Human Resources for Health
The major barriers to human resources for health mentioned were the inadequate staff to run the work in the health center and insufficient training on HPV vaccine.
“We have few staff, which also compromises our service delivery. If some health workers go to the outreach clinic, you can feel the impact in the health facility when a few of us are left here”
(Key Informant 1, Healthy facility in-charge)
Despite the inadequate staff at the health facility, the VHTs and other community mobilisers support the health workers in mobilizing the community to take their daughters for vaccination thus motivating them. In addition, health workers were motivated to work with the available Primary Health Care (PHC) funds. The team work and role played by the Village health teams and other mobilisers in the community motivated them.
“PHC funds have helped to facilitate vaccinators and this is a good strategy for us. In addition, we use phone messages to thank them for the good work they do despite the hardship” (Key informant 1, District Health Team)
Barriers to Vaccines, supplies and medicines
Inconsistency in vaccine supply was noted in both the checklists and from various key informants and records in health facilities; the first supply of vaccines doses was underestimated
“The inconsistence in vaccine supply is a major barrier to completion of the doses, and it is something that I know is beyond the District Health Office to handle.”
(Key informant 1, DHT)
“Supply of the vaccine is very poor and inconsistent. Despite this, we give out the doses as and when we receive the stock, but in that case, we can’t ascertain the efficacy of the vaccine”
(Key informant 2, DHT)
The integration of the HPV vaccines with other services such as child days plus helps to increase coverage by taking advantage of the existing infrastructure to provide the vaccine. This is expressed by some key informants
“Furthermore, this is an integrated service and people get very many services at once, may be this has contributed to the success”
(Key informant 4, Health facility in-charge)