Role of the health system in influencing uptake of human papillomavirus vaccine among adolescent girls in Mbale District, eastern Uganda: a cross-sectional, mixed-methods study

Abstract

Abstract Background Cervical cancer ranks as the most common cancer among women in Uganda, and prevalence has increased by 1·8% per annum over the past 20 years. Human papillomavirus (HPV) is responsible for more than 90% of cases of cervical cancer. The availability of an HPV vaccine presents an opportunity to prevent cervical cancer; however, national coverage stands at 17% against target coverage of 80% since the vaccine's introduction in 2015. This study assessed the role of the health system in influencing uptake of the HPV vaccine so as to inform vaccine implementation in Uganda. Methods We did a cross-sectional study that employed qualitative and quantitative methods. We did structured interviews among 407 adolescents aged 9–15 years systematically selected using Bennet's cluster survey method from five subcounties in Mbale district and six key informants (district health officials) in May 2017. Adolescents were involved in decision making about where to receive the vaccine. We used the WHO six building blocks framework to assess health system factors. Nine health facilities were assessed using a WHO checklist for vaccine service delivery. Quantitative data were analysed using Stata version 13. Qualitative data were analysed using MAXQDA version 12. Uptake was defined as receiving two doses of the vaccine. Findings 56 (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=0·002), 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 health system factors that contribute to low uptake. Interpretation Uptake was well below the Ministry of Health target of 80%. 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. Funding None.