Perceptions of Human Papillomavirus Vaccination of Adolescent Schoolgirls in Western Uganda and Their Implications for Acceptability of HPV Vaccination: A Qualitative Study

Conducted nearly 5 years after the initial human papillomavirus (HPV) vaccination of adolescent schoolgirls in Ibanda district, Uganda, this qualitative study explored the community's initial reactions to the vaccinations, how they changed over time, and the implications of their perceptions for acceptability of HPV vaccination of adolescent girls in the district.

According to the researchers, very few studies exploring changing perceptions of parents and other stakeholders following the introduction of HPV vaccination have been conducted in developing countries generally and in sub-Saharan Africa in particular. Previous studies conducted in low-resource settings prior to the introduction of HPV vaccination found that understanding of cervical cancer and HPV was limited, but sentiments toward cervical cancer vaccination were positive. There were concerns about quality of delivery, safety, adverse effects, and the effects of the vaccination on girls' fertility. The majority of studies that have explored community perceptions of HPV vaccination elsewhere have mainly used cross-sectional quantitative surveys.

As this article details, between 2008 and 2011, adolescent girls (aged 13-16) in primary schools in Ibanda district were vaccinated annually against HPV as part of a demonstration project by the Uganda Government and Program for Appropriate Technology for Health (PATH) to evaluate different HPV vaccine delivery strategies for low-resource settings. Mobilisation and sensitisation of communities prior to the introduction of the HPV vaccination and during the vaccinations took place at district, school, and village levels. Posters and other information, education, and communication (IEC) materials were distributed and radio messages aired. These materials explained the HPV vaccinations in greater detail, including how HPV is transmitted and why there was need for HPV vaccination of young adolescents as a protection against cervical cancer. In addition, teachers and health workers were trained and given additional materials for educating others in the community as well as adolescent girls in schools about HPV vaccination.

Any initial misconceptions and concerns about HPV vaccination were largely overcome through this massive mobilisation and sensitisation of communities - hence the relatively high HPV vaccination coverage in Ibanda for all 3 doses, which was estimated at 90.5 and 88.9% for the first and second years of vaccination, respectively.

Regarding the study's theoretical framework, this study was anchored in the first two components of the symbolic interactionism theory. It also borrowed 3 of the 5 Health Belief Model (HBM) constructs, namely: perceived benefits, cues to action, and barriers, which determine the likelihood that an individual engages in a given health-enhancing behaviour.

The qualitative study was carried out in Ibanda district between November and December 2011 using focus group discussions (FGDs) and key informant interviews (KIIs). The FGDs of schoolgirls (4 FGDs) and of parents/guardians (5 FGDs) were conducted separately using pre-tested and translated FGD guides. In addition, 10 KIIs were conducted with teachers, health workers, and community leaders. All key informants were involved in the mobilisation and sensitisation of communities about the HPV vaccination.

Findings from the study are presented using the 3 HBM constructs: perceived benefits, cues to action, and barriers. In brief, community members perceived HPV vaccination favourably in terms of benefits and cues to action, although there were some misconceptions and concerns about vaccination of young girls against HPV that could potentially discourage parents and adolescent girls from HPV vaccination. More specifically:

• Perceived benefits: Based on the messages used during the mobilisation of the communities for the HPV vaccination, the HPV vaccination was understood to safely prevent cervical cancer, which was perceived to be a severe, incurable disease. Health workers and community leaders explained that illness and deaths associated with cervical cancer witnessed in the communities were an eye-opener to parents that cervical cancer is fatal and its prevention is critical. However, schoolgirls' main concern was that cervical cancer jeopardises a woman's ability to bear children. For them, the vaccine means safeguarding their future reproductive health. The study also found some misconceptions of HPV vaccination that paradoxically were likely to encourage parents' and girls' acceptability of HPV vaccination (e.g., that it prevents HIV). Community leaders and school teachers pledged to continue mobilising parents and eligible girls to embrace HPV vaccination.
• Perceived cues to action: Vaccinations were perceived as protection against diseases like measles and polio that were known to kill children. Parents who had positive experiences with other childhood vaccinations considered HPV vaccination to be as safe as any other vaccination they were familiar with. The main complaints by vaccinated girls were pain and minor swellings around the injection points, which were reportedly characteristic of all injections and were familiar complaints to the parents. Key informants indicated that perceived safety of the HPV vaccine was a major motivation for parents' willingness to have their daughters vaccinated against HPV.
• Potential barriers: Findings from this study revealed various continuing misconceptions about HPV vaccination, which could lead to hesitancy. For example, some parents and schoolgirls continued worrying that the vaccination could be dangerous to the girls' future fertility, despite the pre-vaccination sensitisation that emphasised the contrary. All the key informants pointed out, however, that these misconceptions were largely corrected through sensitisation. Misconceptions about safety of the HPV vaccination were largely based on previous experiences of adverse effects of other vaccinations. Parents and teachers indicated that some groups in Ibanda considered vaccinations in general as religious and cultural transgressions. Some also blamed a locally prominent radical traditionalist and Pan Africanist for having campaigned against all vaccinations via his FM radio.

In all, perceived benefits of HPV vaccination and cues to action seem to have greatly outweighed the potential barriers to the vaccination. However, the findings point to a need for HPV vaccine promotional activities to gather and disseminate adequate information to plug the suggested information gaps. The researchers suggest that efforts to promote vaccination against HPV should clearly articulate the non-serious nature of the vaccination's known adverse effects, their remedies, and brevity. They should also include deliberate strategies to neutralise negative rumours about the vaccine. The finding that vaccination against HPV contradicts the religious and cultural values of some community members suggests a need for religiously and culturally sensitive strategies to overcome these barriers.