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

""Respecting individuals' beliefs and lifestyles while providing scientifically sound information by trusted healthcare professionals, including risks and benefits of vaccination is fundamental in helping people understand the rationale and benefits of vaccination..."

Population-based surveys indicate that vaccination with the 2-dose human papillomavirus (HPV) vaccine series among adolescent girls in Uganda has remained low since the vaccine was included into the routine national immunisation programme in November 2015. This study explored barriers that prevent eligible girls from initiating or completing the recommended 2-dose HPV vaccine series in Oyam District, Northern Uganda.

The study site was selected purposively, being one of the 12 districts in which the HPV vaccination programme was introduced as a pilot in 2012. The researchers conducted 40 interviews with adolescent girls, their caregivers, village health team (VHT) members, health workers, and school administrators involved in HPV vaccination. The content thematic approach for analysis was guided by the Social Ecological Model, which provided a basis for identifying and locating barriers at individual, organisational (health facility), and community levels. Quotations illustrative of the barriers to vaccination were identified and used in the presentation of the study findings.

Examples of findings include:

• Individual-level barriers: Girls' inadequate knowledge about the HPV vaccine; caregivers; lack of awareness of the HPV vaccine and vaccination activities; girls' frequent mobility between vaccine doses; school absenteeism (e.g., due to caregivers' stopping the girls from attending school to help out with domestic work); school drop out between doses due to girls' marriage or pregnancy coupled with fear and embarrassment to return to their former schools to complete the vaccine series; fear of injection pain; physical barriers such as impassable roads; and discouragement from caregivers or peers were key barriers.
• Barriers at the health facility level: Limited knowledge about the HPV vaccine and the national HPV vaccination policy on the part of healthcare workers, VHTs, and teachers; lack of strategies to reach out-of-school girls with information and vaccination programme activities; vaccine supply shortages and inadequacies of the cold chain infrastructure; unpredictable transportation for staff and vaccine, resulting in irregular outreach; limited social mobilisation and community engagement to promote the vaccine; lack of reminder strategies after the first dose of the vaccine; and un-friendly behaviour of some healthcare workers.
• Community-level barriers include:
  • Rumours or misconceptions about the vaccine and vaccination: Community members were concerned that the vaccine would lead their girls to think they are protected from all sexually transmitted infections and encourage early sexual debut.
  • Concerns about safety and efficacy of the vaccine: For instance, community members feared potential long-term side effects of the vaccine, which they worried could lead to poor pregnancy outcomes, including miscarriages and infertility.
  • Negative religious and cultural beliefs about vaccination: VHTs and healthcare workers reported that some traditional practices and religious beliefs were against vaccination.
  • Rumours and misconceptions: Rumours circulating in some communities suggested that the vaccine could be a source of other infections like HIV and conditions like diabetes and cancer.
  • Mistrust in government intentions to introduce a vaccine marketed for girls: Some community members were suspicious that government is using new vaccines for population control.
  • Busy schedules and the gendered nature of care work were key community level barriers: "Some parents...see that it is only the garden work that is important" - healthcare worker.

Thus, this study revealed an interplay of barriers at individual, health facility, and community levels that prevent initiation and completion of HPV vaccination among adolescent girls in Oyam District. In addition to efforts to strengthen the health system, among the suggestions for addressing these barriers: "an intensive communication strategy with culturally appropriate messages to raise awareness about the HPV vaccine, change attitudes of communities about the vaccine and motivate caregivers to encourage their daughters to be vaccinated." Findings from other studies cited here "highlight a need for caregiver education about HPV vaccination. Where intensified social mobilization and community sensitization campaigns have been implemented, there was an increase in demand for vaccination....HPV program evaluations have shown the importance of vaccination programs to be jointly 'owned' by both immunization programs and education institutions, for consent, social mobilization, logistics and monitoring..."

In conclusion: "Active and continuous collaboration between ministries of health and education, community mobilization and sensitization by health workers, the media, teachers, local leaders and community health workers as well as active community follow-up of girls out-of-school and those that miss vaccination at school are key strategies..."