Knowledge, Attitude and Practice of Main Stakeholders towards Human Papilloma Virus Infection and Vaccination in Mombasa and Tana-River Counties in Kenya: A Qualitative Study

"Community involvement and pre-vaccination preparedness...may aid in vaccine acceptance consequently influencing the uptake of the HPV vaccination..."

The need to introduce human papillomavirus (HPV) vaccination is especially urgent in developing countries, including Eastern African countries, where there is a high burden of cervical cancer. Following an HPV vaccination pilot in 2013-2015 in Kitui county, Kenya introduced the HPV vaccine in October 2019 with a goal to immunise approximately 800,000 girls annually against HPV. Generally, the perception of Kenyan communities with regard to HPV vaccination revolves around perceived mistrust towards new vaccinations, insufficient knowledge about HPV infections and HPV vaccination, and high levels of misinformation. This study assessed the knowledge, attitudes, and practice of affected groups towards HPV infection and introduction of HPV vaccination to 10- and 11-year-old boys and girls in the coastal region of Kenya.

From September 2020 to February 2021, the researchers conducted semi-structured interviews among 26 children aged between 9-13 years of age and 76 key informants including parents, head teachers, community leaders, and health workers involved in HPV vaccination in Mombasa (urban and comparatively wealthy) and Tana-River (rural and comparatively underdeveloped) counties.

The findings indicate that a significant proportion of participants, especially children, have limited knowledge of HPV. However, many participants were aware of the HPV vaccine as a preventive measure. Quite a few participants (n = 72) believe the HPV vaccine is ineffective in boys because they do not have a cervix. Safety concerns were the most significant determinant of attitudes, and many alleged that the HPV vaccine is associated with birth control. One community leader said, "mostly the people who are living in this locality are Muslims, family planning is prohibited in the holy Quran that is their perception". Most of the participants mentioned that the local culture (sense that the community was opposed to it) was an impediment to HPV vaccination. Others pointed to the newness of the vaccine and expressed a fear of the unknown. Parents and community members are not in favour of HPV vaccination, as compared to teachers, health workers, and community leaders. A similar pattern of inadequate knowledge and strongly opposed attitudes was observed in Mombasa and Tana-River.

Interviews demonstrated that children, health workers, and parents were involved in making informed decisions about HPV vaccination. From the findings, the adolescent girls exercised a high level of autonomy, as demonstrated by the nurses' response to the question on how the adolescent girls felt about being vaccinated. The nurses did not express any difficulty initiating conversations about sex with the adolescents.

Going forward, most of the participants stressed the importance of sensitisation, with one parent saying, "it would be good for the community to be sensitized so that they know the importance of the vaccine". One health worker who was interviewed commented, "We will also like to involve the politicians, the spiritual leaders because they are the people who influence most of the peoples' decisions, so if we involve them at least to create a positive impact when it comes to the vaccination and also if the ministry of education works together with the ministry of health to ensure that each and every girl gets the jab; at least no girl is left behind".

Other suggestions to emerge from the study include:

• Ensure adequate training and other information channels: Information available in the community is derived mainly from seminars and workshops arranged by health authorities; apparently, the information given to girls and parents prior to vaccination is suboptimal.
• In light of misunderstandings about the purpose of HPV vaccination for boys, as well as misinformation, actively involve health workers in dialogues to address the parents' and community's confusion and concerns. Capacity-building of health workers and community leaders is essential, as they are the drivers of disseminating correct information to the community.
• Considering that cultural norms and religious factors have shaped the HPV vaccination landscape, conduct HPV vaccine promotion campaigns geared toward the community and leaders such as village elders, who can then ensure information reaches their peers/people.
• Make plans to restart HPV vaccination programmes that were interrupted by the COVID-19 pandemic. HPV vaccination programmes at schools were halted due to the lockdown, and girls either missed or had delays for the second doses. In addition, as reported here, safety and efficacy concerns related to the COVID-19 vaccine - not only in Kenya but across countries - may have influenced the uptake of HPV vaccination as well.

In conclusion: "A grassroots social mobilization is needed to improve the willingness of the population to vaccinate, with accurate information for parents and teachers, who are key implementers and promoters of HPV vaccination (yet often do not support vaccination). In addition, a campaign to reach children is critical; although they cannot decide on their own, [the] results demonstrate that parents in Kenya take their concerns into account. Future studies should focus on mass awareness and education about HPV vaccination and cervical cancer, as well as efficacy of innovative ways and tactics to deliver messages to the community."