"When You Get the HPV Vaccine, It Will Prevent Cervical Cancer; It Will Act as a Shield": Adolescent Girls' Knowledge and Perceptions Regarding the Human Papillomavirus Vaccine in Zambia

"...reinforces the earlier findings by other researchers among multiple stakeholders of low to moderate knowledge, positive attitudes, and perceived barriers amid high acceptability and low HPV vaccine uptake. It is important for policymakers to consider suggestions made by adolescent girls for the continued program implementation."

The human papillomavirus (HPV) vaccination is an important preventive measure for HPV-related conditions such as cervical cancer. In 2019, Zambia introduced a free national HPV vaccination programme for 14-year-old girls. However, uptake has been low due to factors such as parental refusal, beliefs in myths and misinformation, and school closures due to the COVID-19 pandemic. Zambia's reported coverage for dose one of the HPV vaccine series in 2019 was 75%, which dropped to 39% in 2021 owing to some of these factors. In Zambia, most research has focused on other stakeholders, such as parents and healthcare workers. This study sought to understand the knowledge and perceptions of adolescent girls themselves regarding the HPV vaccine and to discuss acceptability and uptake implications.

The Ministries of Health and General Education collaborate in implementing the HPV vaccination programme. The number of eligible girls is determined using school registers, headcount, and Central Statistics Office figures. At the same time, community health workers identify out-of-school girls in a door-to-door fashion or through civil societies; these girls receive the vaccine from health facilities or community outreach points.

Between June 2021 and November 2021, the researchers conducted an exploratory qualitative study using semi-structured interviews with 30 adolescent girls aged 15–18 years within selected schools and health facilities of Lusaka district, the capital city of Zambia. This study is partly framed within the health belief model (HBM), a theory commonly used for exploring perceptions that may influence health-seeking behaviour. Some of the questions asked of the participants based on the HBM included: How likely are you to get infected with HPV, how severe would the HPV infection be if you got infected, what do you think are the benefits of getting the HPV vaccine, and what are the barriers to getting the HPV vaccine?

Seventeen girls reported having received at least one dose of the HPV vaccine. Participants expressed variable knowledge and awareness about HPV and the HPV vaccine. Some girls felt they were not susceptible to HPV infection as they were not sexually active; hence, did not feel the need to take the HPV vaccine until they were older and sexually active. Some adolescent girls discussed circumstances beyond their control, such as being raped, which could put them at risk of infection with HPV. In general, participants exhibited positive attitudes towards the HPV vaccine and perceived it as beneficial, which is likely to increase its acceptability and uptake. "[M]uch effort is required to ride on these positive attitudes, because previous studies showed that in some instances, high acceptability did not translate into high HPV vaccine uptake..."

However, there were multiple perceived barriers to vaccination, such as not being in school, concerns about vaccine side effects, and belief in myths (e.g., that the vaccine is meant to sterilise girls). The misinformation was worsened by the introduction of the COVID-19 vaccine, where the community assumed that adolescents were secretly being inoculated with the COVID-19 vaccine within the pretext of administering the HPV vaccine. Participants also reported conflict between mothers and daughters, as some adolescents were willing to receive the vaccine but were discouraged or stopped by parents, especially mothers. The study also showed that when mothers expressed support or encouragement, there was no resistance by the girls. This finding indicates that mothers should be a focus of strategies aiming to increase HPV vaccine uptake. Parents and elders in general are held in high esteem, especially in conservative cultures in the African context, and decisions regarding their children are usually final without any further discussion, as they are perceived to be in the best interest of the child. Participants reported that peers also influenced their reactions to the vaccine - either positively or negatively. "[W]ith active engagement and education, peers can play a critical role in increasing HPV vaccine uptake if they are knowledgeable and they themselves have experienced vaccination."

Adolescents had several suggestions for increasing HPV vaccination amidst mixed messages. Some suggestions related to increasing knowledge and awareness of HPV vaccination by making information about HPV vaccination more accessible within communities through social mobilisation campaigns, including information on HPV within the school curriculum and communnity sensitisation for those out of school, as well as the active involvement of politicians.

From the researchers' perspective, the findings of mixed knowledge among participants could be explained by the HPV vaccination programme being in its infancy, and hopefully, as it matures, more people may be aware through access to information about the HPV vaccine. Culturally appropriate and contextualized strategies could be implemented with the aim of raising awareness and improving knowledge, and subsequently improving HPV vaccine uptake. Examples of strategies include messages around the HPV vaccine packaged in an easy-to-understand format and language using the most accessible platforms (door-to-door campaigns, churches, markets, schools, and health facilities) to ensure widespread information sharing.

In addition, further studies to understand factors influencing parental decision-making for their daughter's vaccination should be considered to aid in mitigating experienced barriers. There has been a gradual increase and sustainable coverage of other childhood vaccines in Zambia in the period 2000-2018 owing to strong communication, collaboration, and coordination in the background of strong health systems. Therefore, considering the relative novelty of the HPV vaccine in Zambia, applying strategies that have been used to improve other vaccine coverage may be necessary. Parents who hold fast to myths and misconceptions coupled with low education levels are more likely to decline vaccinating their daughters as so may need tailored messaging and engagement strategies to be reached.

Further, even though the current national guidelines entail a girls-only vaccination programme in Zambia, a future study involving boys is necessary because as the vaccine becomes more available, gender-neutral HPV vaccination will become policy.

In conclusion: "To support increased HPV vaccine acceptability and uptake among adolescent girls in Zambia, it is critical to actively engage stakeholders involved in HPV vaccination, such as adolescents and their parents, and debunk myths and misconceptions about HPV vaccination. Health education in schools and communities should be implemented to increase knowledge about HPV and HPV vaccination among adolescents and their parents."