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Background: Globally, cervical cancer is the fourth most common cancer in women with more than 85% of the burden in developing countries. In Uganda, cervical cancer has shown an increase of 1.8% per annum over the last 20 years. The availability of the Human Papillomavirus (HPV) vaccine presents an opportunity to prevent cervical cancer. Understanding how the health system influences uptake of the vaccine is critical to improve it. This study aimed to assess how the health systems is influencing uptake of HPV vaccine so as to inform policy for vaccine implementation and uptake in Mbale district, Eastern Uganda. Methods: We conducted a cross sectional study of 407 respondents, selected from 56 villages. Six key informant interviews were conducted with District Health Officials involved in implementation of the HPV vaccine. Quantitative data was analyzed using Stata V.13. Prevalence ratios with their confidence intervals were reported. Qualitative data was audio recorded, transcribed verbatim and analyzed using MAXQDA V.12, using the six steps of thematic analysis developed by Braun and Clarke. Results: Fifty six (14%) of 407 adolescents self-reported vaccine uptake. 182 (52.3%) of 348 reported lack of awareness about the HPV vaccine as the major reason for not having received it. Receiving vaccines from outreach clinics (p = 0.02), having many options from which to receive the vaccine (p = 0.02), getting an explanation on possible side-effects (p = 0.024), and receiving the vaccine alongside other services (p = 0.024) were positively associated with uptake. Key informants reported inconsistency in vaccine supply, inadequate training on HPV vaccine, and the lack of a clear target for HPV vaccine coverage as the factors that contribute to low uptake. Conclusion: We recommend training of health workers to provide adequate information on HPV vaccine, raising awareness of the vaccine in markets, schools, and radio talk shows, and communicating the target to health workers. Uptake of the HPV vaccine was lower than the Ministry of Health target of 80%. We recommend training of health workers to clearly provide adequate information on HPV vaccine, increasing awareness about the vaccine to the adolescents and increasing access for girls in and out of school.
We conducted a cross-sectional study in Mbale district in Eastern Uganda. Mbale district has a population of 488,990 people of which 52.3% are female, and 21% are between 10 and 17 years of age. The district was among the first districts where the HPV vaccination program was first implemented in 2012. We used a structured questionnaire to interview the adolescent girls. we held six key informant interviews with health workers in the district. The quantitative and qualitative data collection methods helped to obtain convergence and substantiation among the different health system factors. The multiple perspectives aimed to provide an opportunity to develop a more complete understanding of the health system factors influencing HPV vaccine uptake. The study enrolled female adolescents aged 9–15 years because they were expected to be in Primary four or within the expected age group for the vaccination schedule. Quantitative data were selected using a structure questionnaire, in a multi stage cross sectional design. We used Bennett’s cluster survey sampling formula taking an assumption of a prevalence of 50%, a precision of 0.032 [16] and a margin of error of 5%. The sample size was 392 respondents. On adjusting for non-response, at a rate of 10%, the final sample size was 431 respondents. The study used a three-stage sampling procedure; in the first stage, we randomly selected five sub-counties out of the twenty in the district. In this study, a cluster was equivalent to a village. We randomly selected five sub-counties out of the twenty-three and from each sub county, we selected two parishes to give a total of ten parishes. A list of all villages from the selected parishes was then used to randomly select the total of 56 villages. We then interviewed seven adolescents 9–15 years, eligible for the HPV vaccine from each village using the Village Health Team’s (VHT) guide, and taking only those who were residents of the selected villages in Mbale district for at least 2 years. A consideration of 2 years was taken because the national rollout of the vaccine was done in 2015. Care takers and adolescents who were not found in their homes after three consecutive visits were replaced with the next household. If a care taker was too ill to take the interview, they were excluded and replaced. Health system factors were assessed through key informant interviews and an observation checklist. We conducted six key informant interviews with the district health team members who had an expert opinion about the health services factors that influence uptake of HPV vaccination in the district. The district team members included the following: the District Health Officer for maternal and child health, the District Cold Chain Technician and health facility In-charges. The numbers of Key Informant Interviews were deemed sufficient when additional interviews yielded little new information on the core study objectives. The interviews were audio recorded after informed verbal consent was obtained from the participants. We observed for key vaccines, supplies in selected health facilities within the sub-counties using the World Health Organization (WHO) checklist for vaccines and supplies. The dependent variable was uptake of the HPV vaccine, this was measured by having a vaccination card that indicates the number of doses attained and recall of obtaining an injection on the left upper arm if the child was between 9 and 15 years. Initiation was defined as having received at least one of the recommended two dose series of the HPV vaccine and Uptake was defined as completing the two doses of the HPV vaccine. Quantitative data were entered into Excel 2010, and then exported to Stata Version 13 for statistical analysis. The data were97 summarized into frequencies and proportions for categorical variables and mean. At bivariate level of analysis, Prevalence Ratio (PR) measure was used to assess relationship between the dependent variable (HPV vaccine uptake) and the independent factors. The prevalence ratios were computed using a generalized linear model with Poisson family and a log link with robust errors. At multivariable analysis, all the independent factors with a P value less than 0.15 at bivariate analysis were included in the multivariable model to obtain the adjusted Prevalence ratios. The backward elimination approach was used to obtain the best model with the log likelihood that was closer to zero. The significance level for all the analysis was set at P ≤ 0.05. The model comprised of age group, tribe, religion, and occupation, having many options from which to receive the HPV vaccine, knowing where to report side effects, having received any other vaccines, getting HPV vaccine together with other services, knowing where to report the side effects, and receiving adequate information about the vaccine. For qualitative data, audio tape recordings were all together transcribed verbatim, coded and uploaded qualitative data analysis software MAXQDA version 12. Recurring themes were identified within and between each interview [17]. Two independent researchers were involved in coding. These transcripts were scrutinized to ensure reliability in the use of codes between the coders. The independent lists of codes were reviewed to assess inter-coder agreement. Discrepancies were clarified and resolved by comparing each coder’s results with raw data until consensus was reached. A list of codes was then finalized. The codes were based on the study objectives. Data was then condensed through expressive, text-based summaries and data display matrices. The matrices facilitated to distinguish among the themes and groups. Quotes were then selected that were representative of the main themes.
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