This household-based cross-sectional study among adolescent females aged 11 to 15 years in Kabarole district, HPV vaccination coverage was at 63%. Uganda Ministry of Health reported an annualized HPV coverage of 85% for HPV 1 and as low as 41% (Patrick et al., 2022)for HPV 2 as of December 2017(WHO 2019). In Kabarole district, they reported high HPV1 vaccine coverage at 114%, but still very low HPV2 vaccine coverage at 51% in 2017 (Ministry of Health 2017), HPV1 at 110% and HPV2 at 50% in 2018 (Ministry of Health 2018) and HPV 1 at 91% and HPV2 at 64% in 2019 (Ministry of Health 2019) this is in line with the findings from the study by Chuang et al who concluded that efforts to improve HPV initiation and completion could benefit from additional attention to factors at the health care (Chuang et al., 2017). According to a study carried out in Soweto South Africa, of 224 adolescents recruited, 201 initiated the vaccine; 192 (95.5%) received a second immunization; and 164 (81.6%) completed three doses. In that qualitative study, of 39 adolescent-caregivers, it was found out that factors driving vaccine uptake reflected a socio-cultural backdrop of high HIV endemnicity, sexual violence, poverty, and an abundance of female-headed households (Katz et al. 2013; Bair et al., 2008).
Findings from a study by Migoneetal, HPV vaccine uptake in Ireland was high. Even in schools that are disadvantaged, HPV was above the national target of 80%. Since then, anti-HPV vaccine publicity has had a negative impact on national HPV vaccine uptake in Irish schools. The study also found out that even notwithstanding recent anti- HPV vaccine publicity, school-based programmes, such as the Irish HPV vaccination programme have been shown to maximize uptake of vaccines when compared with opportunistic community based programmes (Kessels et al., 2012).
The study by Migoneetal, demonstrates that inequity in uptake may persist in school based programmes while the difference in mean and median uptake between disadvantaged schools and other Irish schools in Irish study was small, the majority of schools with the lowest uptake (≤ 50%) were disadvantaged. Disadvantaged schools were twice as likely to have an uptake of ≤ 50% when compared with other schools, independent of other school characteristics (Kessels et al., 2012).
Lower HPV vaccine uptake in disadvantaged schools has been reported by other studies; In Manchester, uptake was significantly lower in more deprived areas while in Ontario, Canada, uptake of HPV vaccine in schools was lower in girls from lower income backgrounds (Fisher et al., 2014).
Findings from a longitudinal study carried out in Eldoret, Kenya, where HPV vaccine acceptability was measured before a vaccination program (n = 287) and vaccine uptake, as reported by mothers, once the program was finished (n = 256) indicates that even though baseline acceptance was very high (88.1%), only 31.1% of the women reported at follow-up that their daughters had been vaccinated. The vaccine was declined by 17.7%, while another 51.2% had wanted the vaccination but were obstructed by practical barriers including cultural acceptance related barriers (Joseph et al., 2012; Vermandere et al., 2014).
A study conducted in Lira district, Uganda, on the level and factors associated with the uptake of HPV vaccine among adolescent girls aged between 12 and 17 years also demonstrated low uptake where 49.6%(228/460) had not taken any of the vaccines, 18%(83/460) had received one dose, 14.8%(68/460) had received two doses and the uptake was associated with factors like education and other social economic factors (Kisaakye et al., 2018; Isabirye et al., 2020) .
Knowledge of HPV vaccination and distance to facility were the factors associated with uptake of Human papilloma virus vaccine among adolescent girls aged 11 to 15 years in Kabarole district.
Baseline information on knowledge, attitude and practice towards HPV vaccination was crucial in establishing a progress track on the current HPV immunization program (Jalani et al., 2019). In a study conducted in Malaysia with a total sample of 380 respondents who participated in this study. Females scored significantly higher for the knowledge items compared to the males. Majority of respondents (86.6%) indicated their intention to get HPV vaccines. Willingness to be vaccinated was significantly associated with the level of knowledge of cervical cancer (AOR 1.66; 95% CI 1.018–2.698; p = 0.042). Gender (AOR 3.29; 95% CI 2.00-5.41; p < 0.001) lack of knowledge was found to be a significant predictor for someone who rejects vaccination due to side effects (Jalani et al., 2019).
The study conducted by Satterwhite CL in Malaysia concluded that knowledge of HPV and its preventive measures among the respondents were still insufficient. Attitude towards HPV vaccination was significantly associated with knowledge about cervical cancer (Lechuga et al., 2011). In addition, vaccination practice among secondary school girls was high, indicating that the national HPV immunization program was effective in delivering the HPV vaccine (Satterwhite et al., 2013).
Since acceptance of HPV vaccination varies internationally, and many adolescents were still not getting the HPV vaccine in various countries (Wigle et al., 2013), it was important to understand why some parents choose to vaccinate their children and some parents do not in order to continue to increase vaccination uptake. According to the study conducted by Brooke Nickel 2017, both low and high HPV knowledge may be associated with lower rates of vaccination, with parents' country and gender also being influential factors. It also demonstrated that parental attitudes towards the HPV vaccine differ by country and knowledge (Nickel et al., 2017).
Given that the primary target population for HPV vaccination program was girls aged 9–13, typically before the initiation of sexual accident, parental knowledge and attitudes play an important role in the success of vaccination as consent was usually required for their adolescent children to be vaccinated. Research aimed at understanding HPV vaccine uptake has demonstrated that uptake of the HPV vaccine was generally high with good knowledge about the vaccine, however parents and girls often had insufficient knowledge and understanding about and had varying attitudes towards vaccination (Hendry et al., 2013). Alongside this, several studies conducted across different settings have aimed to examine factors influencing HPV vaccine uptake. Findings from these studies were wide-ranging, however, parental intentions have been shown to consistently be a strong predictor of their children's HPV vaccine uptake (C. J. Alberts et al., 2017).
According to the findings by Brooke 2017, the strongest factor associated with daughters' vaccination status across the entire sample was parents' HPV knowledge (p < 0.001). Parents' HPV knowledge scores displayed a non-linear relationship; parents with low knowledge scores and parents with high knowledge scores were less likely to have vaccinated their daughters. HPV vaccination specific knowledge was also significant univariate factor associated with vaccination status (p < 0.05) (Hendry et al., 2013).
Vaccination specific knowledge and very high levels of vaccination specific knowledge were also less likely to have vaccinated their daughters. Parents' demographic characteristics including their country of origin (OR = 2.2, 95% CI: 1.07–4.50; p < 0.05) and gender (OR = 0.5 95% CI: 0.26–0.94, p < 0.05) were also factors associated with non-vaccination, with parents in the US and men (across all countries) being less likely to vaccinate their daughters (Kessels et al., 2012).
This is also in line with a study conducted in Ethiopia Debre Tabar Town by Gedefaye in which secondary education and above (AOR 1.70, 95% CI 1.05–2.27) and having good knowledge of the HPV vaccine (AOR 3.30, 95% CI 2.21–4.93) were significantly associated with willingness to receive the HPV vaccine.
From the qualitative analysis, it was reported that some villages in Kabende are hard to reach and it is worse in the rainy season when the road network is poor. This is consistent with the findings on the quantitative analysis where long distance to the health facilities (Nabirye et al., 2020) was associated with poor uptake of the vaccination. The long distance with a poor road network makes it hard for the adolescents to access the vaccination points (Kessels et al., 2012).
In Summary, the findings in this study are consistent with the results in other studies where the uptake and completion of the vaccination programme is still a challenge (Joseph et al., 2012).
Also the findings on the factors associated with the uptake from this study are consistent with the findings in other studies where knowledge about the vaccine by both the adolescent girl and caretaker, level of education by the caretaker and accessibility to the vaccination points are strongly associated with uptake of the vaccine (Kahn et al., 2007).
From this study, it was also established that most HPV vaccination programmes target girls aged less than 12 years old or those in primary school, which enables them to get the best protection. Most girls at secondary school level have already started sexual debut, so it is very important for them to complete the HPV vaccination before they start secondary education(Whelan, 2016).