Uptake of human papillomavirus vaccine among school girls and its associated factors in Addis Ababa,Ethiopia

Abstract

Objectives

To assess the HPV vaccine uptake among adolescent public high school girls aged 15-19 years and the factors associated with it in Addis Ababa, Ethiopia.

Methods

A school-based cross-sectional study was conducted among 754 adolescent public high school girls aged 15-19 years in Addis Ababa. A multistage cluster sampling technique was used, and data were collected using a structured self-administered questionnaire. Data were analyzed using Stata version 14. We calculated the proportion (95% CI) to measure uptake. A multivariable logistic regression analysis was used to identify the factors associated with HPV vaccine uptake.

Results

HPV vaccine uptake was reported by 55.3% (95% CI: 51.7%, 58.8%) of school girls aged 15-19 years. Knowing the HPV vaccine [AOR=3.0, (95% CI:2.2, 4.2), p-value 0.001] and a positive attitude toward the HPV vaccine [AOR=3.3, (95% CI:1.6, 6.9), p-value 0.001] were significantly associated with HPV vaccine uptake.

Conclusions

Half of the school girls in the study area received the HPV vaccine. Interventions that enhance knowledge about the HPV vaccine and a positive attitude towards it can increase HPV vaccine uptake among schoolgirls.

Keywords

Addis Ababa adolescent public high school girls HPV vaccine risk factors uptake

Introduction

Cervical cancer is one of the world’s major public health problems, caused by oncogenic and sexually transmitted types of Human Papillomavirus (HPV).¹ Globally, the annual incidence of cervical cancer has been projected to increase from 570,000 to 700,000 between 2018 and 2030, with the annual mortality projected to increase from 311,000 to 400,000². It is estimated that annually, 7,095 cases of cervical cancer and 4,732 deaths from cervical cancer in Ethiopia.²

Cervical cancer is the only vaccine-preventable cancerous disease.³ The HPV vaccine is an economical way to prevent cervical cancer.^4,5 The Food and Drug Administration (FDA) has approved three prophylactic vaccines: Gardasil, Cervarix, and Gardasil9. The Cervarix (bivalent) and Gardasil (quadrivalent) vaccines protect against HPV types 16 and 18 infections. The quadrivalent vaccine (Gardasil) protects against anogenital warts caused by HPV types 6 and 11⁶

The World Health Organization (WHO) recommends a primary prevention strategy that includes routine HPV vaccination for girls aged 9-14 years. Many countries have implemented school-based immunization programs to increase vaccination rates among adolescents.⁷ In Ethiopia, the quadrivalent HPV vaccine (Gardasil), targeting HPV types 6, 11, 16, and 18, was first introduced in 2018 with support from the Global Alliance for Vaccines and Immunization (GAVI). The vaccine was introduced for a single-age cohort of girls aged 14 years with two doses at a 6-month interval.⁸ However, to the best of our knowledge, there is no evidence on the uptake of the HPV vaccine among adolescent public high school girls aged 15-19 years and its associated factors in Addis Ababa.

Globally, the uptake of the HPV vaccine ranged from 2.4% to 94.4%. Scotland had the highest magnitude of uptake, whereas Hong Kong had the lowest level of uptake of the HPV vaccine.^9–11 The uptake of the HPV vaccine in African countries ranges from 0.5% to 63.8%. The status of the uptake of the HPV vaccine in Benin City, Nigeria, was 0.5%¹² in the Lira district of Uganda was 17.6%¹³ in South Africa was 19.4%,¹⁴ and in Kenya was 63.8%.¹⁵

In Ethiopia, researchers conducted studies to estimate HPV vaccine uptake across different regions of the country. The summary of HPV vaccine uptake across different geographical locations in Ethiopia is presented in Table 1. In Nekemte city, the level of uptake of the HPV vaccine was 61.2% among adolescent high school girls.¹⁶ Among school girls in Ambo town, the HPV vaccine uptake was reported at 44.4%.¹⁷ In Bahir Dar, willingness to be vaccinated in primary school was 50.6%, whereas in preparatory school, HPV vaccine uptake was 16%.^18,19 The magnitude of HPV vaccine uptake in Gambella was 48%.²⁰ In Arba-Minch, the level of acceptance of the HPV vaccine among adolescent girls was 50.4%.²¹ In Minjar-Shenkora, the acceptance of the HPV vaccine among girls in primary school was 66.5%.²² In Debre Tabor, acceptance rate of the HPV vaccine was 61.9%²³ (Table 1).

Table 1.

Literature review on the status of the HPV vaccine uptake and factors affecting the uptake in Ethiopia.

Study area	Sample size	Study participants	HPV vaccine uptake (%) 95% CI	Factors affecting uptake of the HPV vaccine	References
Bahir Dar	820	Primary school/10-19 years old	50.6 (47.4-54.0)	Maternal educational status, attitude	18
Bahir Dar	633	Preparatory school	16.8 (17.7-21.2)	Knowledge about the HPV vaccine and attitude	19
Gambella	882	Adolescent	48 (44.6-51.4)	Knowledge and attitude	20
Nekemte	626	High school/9-15 years old	61.2 (57.2-65.0)	Knowledge and attitude	16
Ambo	422	School girls	44.4 (40.0-49.2)	Knowledge and attitude	17
Arba-Minch	561	Adolescent girls/13-14 years old	50.4 (45.9-55.2)	Knowledge, age, maternal educational status, attitude	21
Minjar- Shenkora	591	Primary school	66.5 (63.0-70.0)	Knowledge and attitude	22
Debre Tabor	832	Adolescent girls	61.9 (62.6-69.0)	Knowledge	23
Harari	416	Adolescent school girls	49.3 (42.7-56.59)	Urban residents, having a government-employed mother, availability of health promotion in their vicinity and knowledge	24
Sidama	833	Adolescent girls	49.6 (46.2–53.0)	Urban residence, educational status, knowledge and attitude	25

Globally, studies have been conducted to identify factors associated with HPV vaccine uptake. The following factors affect age,^13,26,27 parents’ education²⁶ and knowledge about the HPV vaccine,²⁷attitude towards the HPV vaccine^13,27 and religious/spiritual belief²⁸ were identified as related to HPV vaccine uptake.

In Ethiopia, studies have been conducted to identify factors associated with the uptake of the HPV vaccine. Two separate studies were done in Bahir Dar, one on primary and the other on preparatory schools, which showed different factors influencing the uptake of the HPV vaccine. In primary school, the factors associated with the willingness to uptake the HPV vaccine were maternal educational status, perceived status, cues to action, and self-efficacy.¹⁸ Whereas in preparatory school, knowledge about the HPV vaccine and attitude towards the vaccine were significantly related to the uptake of the HPV vaccine.¹⁹ In Gambella, factors significantly related to the uptake of the HPV vaccine were knowledge about the HPV vaccine.²⁰ In Arba-Minch, knowledge about the HPV vaccine, attitude towards the HPV vaccine, age, and maternal educational status were significantly related to the acceptance of the HPV vaccine.²¹ In Minjar-Shenkora, knowledge about the HPV vaccine and attitude towards the HPV vaccine were factors identified.²² In Debre Tabor, knowledge about the HPV vaccine was the factor related to the uptake of the HPV vaccine²³ (Table 1).

The conceptual map was developed from the literature.^{13,17–23,26–28} The factors significantly related to the uptake of the HPV vaccine are categorized into sociodemographic characteristics, knowledge about the HPV vaccine, and attitude towards the HPV vaccine (Figure 1).

Figure 1.

Conceptual map.^{13,17–23,26–28}

The WHO recommended that 90% of girls should be vaccinated before 15 years of age to eliminate cervical cancer.²⁹ Ethiopia agreed to provide the HPV vaccine and introduced HPV vaccination for single-age cohorts of girls aged 14 years in 2018.⁸ Studies on the uptake of the HPV vaccine and its associated factors are essential to track the progress of the cervical cancer elimination strategy. However, there is a lack of evidence regarding HPV vaccine uptake and its associated factors in Ethiopia.

In Addis Ababa, studies were conducted to assess knowledge and acceptance of HPV vaccination and associated factors among parents of daughters³⁰; perception, and willingness to receive HPV vaccination among female university students; perceptions and willingness to receive HPV vaccination among female university students³¹; and a qualitative study on the perception of HPV vaccination among middle adolescent school girls.³² However, to the best of our knowledge, there is no evidence on the uptake of the HPV vaccine among adolescent public high school girls aged 15-19 years and its associated factors in Addis Ababa.

Evidence on the uptake of the HPV vaccine and its associated factors provides crucial information to help plan, implement, and evaluate strategies to optimize the uptake of the HPV vaccine.³³ Appropriate information on the level of HPV vaccine uptake and its associated factors would be important for designing measures to improve uptake in Addis Ababa. Therefore, this study aims to assess HPV vaccine uptake and related factors among adolescent public high school girls aged 15-19 in Addis Ababa, Ethiopia.

Methods

Study area

The study was carried out in Addis Ababa, the capital city of Ethiopia. The city covers 540 km2 and is divided into 11 sub-cities. Each sub-city is divided into 10-15 woredas/districts. Each woreda has a health center that provides primary health care, including immunization. Immunization services are also provided in outreach and campaign mode. Basic health services, including maternal and child health care, are provided free of charge in all public health centers. Arada, a sub-city of Addis Ababa, is one of its 11 sub-cities. The Arada sub-city had seven public high schools and 7,896 public high school students, of which 4,436 (56.18%) were female students.³⁴ In Addis Ababa, the HPV vaccine was administered using campaigns in schools or school-based immunization programs for single-age cohorts of girls aged 14 years old.⁸

Study design

A school-based cross-sectional study design was employed to assess HPV vaccine uptake and related factors among adolescent public high school girls aged 15-19 in Addis Ababa, Ethiopia.

Study population

All adolescent girls in public high schools in Addis Ababa, aged 15-19 years, were the source population. All adolescent girls aged 15-19 years enrolled in public high schools in the Arada sub-city for the 2023/24 academic year were considered the study population.

Inclusion and exclusion criteria

Adolescent girls aged 15-19 years in Dej/Belay Zeleke, Bethelhem, and Dagmawi Minilik public high schools who were available in class during data collection, willing, and provided informed consent and assent were included in this study. However, girls who were unwilling to participate and absent from school during data collection were excluded.

Sample size determination

The sample size to estimate the prevalence of the uptake of the HPV vaccine was computed using a single proportion formula with the following assumptions: estimated prevalence of uptake of the HPV vaccine 44.4%,²² 5% marginal error (d), 95% confidence level, and design effect of 1.5 using Epi Info software version 7. The calculated sample size was 569. Finally, with a 10% non-response rate, the calculated final sample size was 633.

The sample sizes to identify factors related to the uptake of the HPV vaccine were determined using a double population proportion formula using Epi Info software version 7 (Table 2).

Table 2.

Sample sizes to identify factors related to the uptake of the HPV vaccine.

Factors	CI	Power	Ratio of cases: Controls	Proportion exposed among controls	OR	Sample cases	Sample control	Total	Reference
Age	95%	80%	1	42.2%	2.9	66	66	132	21
Mothers’ educational status (secondary)	95%	80%	1	48.8%	2.4	96	96	192	21
Mothers’ educational status (more than secondary)	95%	80%	1	67.3%	3.6	71	71	142	21
Knowledge about the HPV vaccine	95%	80%	1	41.5%	2.5	86	86	172	17
Attitude towards the HPV vaccine	95%	80%	1	54.2%	3.2	63	63	126	17

Therefore, the sample sizes computed for the second objective were smaller than those calculated for the first objective; 633 was taken as the final sample size. However, 754 total study participants were enrolled in this study.

Sampling procedure

A multistage-cluster sampling technique was used to select study participants. Arada sub-city, one of the eleven sub-cities of Addis Ababa, was selected using a computer-generated simple random sampling technique. Then, three public high schools (Dej/Belay Zeleke, Bethelhem, and Dagmawi Minilik) were selected using a computer-generated simple random sampling technique from the seven public high schools (Tikur Anbesa, Agazian No3, W/ro Kelemework, Bethelhem, Dej/Belay Zeleke, Meskerem, and Dagmawi Minilik) in Arada sub-city. The sample size for each selected school was allocated proportionally (Figure 2). Then, each grade (9, 10, 11, and 12) and section was selected using a computer-generated simple random sampling method, and finally, all adolescent public high school girls aged 15-19 years from the selected sections were included in the study.

Figure 2.

Schematic presentation of sampling procedure.

Data collection tools and procedures

Data were obtained using a pre-tested, self-administered, and structured questionnaire. The tool was adapted after reviewing previous similar researches.^{17,19,21–23,35} The questionnaire had 5 sections: socio-demographic characteristics, heard about the HPV vaccine, knowledge about the HPV vaccine, attitude towards the HPV vaccine, and HPV vaccine uptake.

The data collection procedure was supervised by facilitators. The data collection took place in the school classrooms during class hours. Male students and teachers were excluded from the class. The female students were arranged to sit separately and/or at a reasonable distance. The participants were given a briefing on their participatory rights and on how to complete the questionnaires. Explanations were provided for the questions raised by the participants. Finally, the completeness of the questionnaires was checked on the spot, and participants were asked to complete any remaining questions.

Data quality control

To ensure the study’s quality, the questionnaire was first prepared in English. The questionnaire was translated into Amharic. The questionnaire was pretested on 5% of the sample from public high schools other than those where the actual study was conducted. Based on the pretest results, necessary modifications were made to the questionnaire before data collection for this study. The principal investigator provided a one-day training session for data collectors covering the study objective, questionnaire content, data collection procedures, methods to assist study participants, and ethical considerations. During the fieldwork, the principal investigator closely followed the data collection procedure. The consistency and completeness of the collected data were checked on each day of activity.

Operational definition

Uptake of HPV vaccine: Refers to participants who reported receiving at least 1 dose of HPV vaccine.^17,19,22

Good knowledge about the HPV vaccine: Good knowledge was considered if participants correctly answered at least 5 of the 10 HPV vaccine knowledge questions.^{17,19,21–23,35}

Positive Attitudes toward the HPV vaccine: Using ten attitude-related questions on a five-point Likert scale, participants were defined as having a positive attitude toward the HPV vaccine if their scores were ≥ 50%^13,21,36,37

Data analysis

The data were entered and cleaned on EpiData version 4.6 (EpiData Association, Denmark, Europe) and exported to STATA version 14 (Stata Corp, College Station, TX, USA) for statistical analysis.³⁸ Descriptive statistics, such as the mean with standard deviation, frequencies, and percentages, were computed and presented in tables to describe the study variables. To estimate the prevalence of HPV vaccine uptake, proportions with 95% confidence intervals were computed. Multivariable logistic regression analysis was performed to identify risk factors for HPV vaccine uptake. All the relevant independent variables involved in the conceptual map were entered into the multivariable logistic regression model, irrespective of their bivariable P-value, because selecting candidate independent variables for the adjusted models based on their univariable P-value could lead to incorrect exclusion of potential confounders and hence lead to inadequate adjustment for confounding.^39,40 In the adjusted model, statistically significant associations were assessed using the adjusted odds ratio (AOR) with the corresponding 95% confidence interval. The Hosmer–Lemeshow model fitness was checked. Results were considered statistically significant at p < 0.05.

Results

The mean age of the study participants was 16.9 years (SD ± 1.2; range 15-19). Regarding parental educational status, 287 (37.5%) and 236 (31.3%) of the study participants’ fathers and mothers had secondary (9-12) education, respectively. 328 (43.1%) of the respondents’ mothers were housewives, and 286 (37.9%) of their fathers were self-employed (Table 3).

Table 3.

Sociodemographic characteristics of adolescent public high school girls aged 15-19 years in Arada sub-city, Addis Ababa, Ethiopia, 2024.

Sociodemographic variable	Category	Frequency	Percent (%)
Age in years	15	118	15.6
	16	176	23.3
	17	204	27.1
	18	189	25.1
	19	67	8.9
Grade level	9	158	21.0
	10	191	25.3
	11	185	24.5
	12	220	29.2
Father’s educational level	Unable to read and write	46	6.0
	Able to read and write	75	10.0
	Primary (1-8)	118	15.7
	Secondary (9-12)	283	37.5
	Diploma	94	12.5
	Degree and above	138	18.3
Mother’s educational level	Unable to read and write	69	9.1
	Able to read and write	101	13.4
	Primary (1-8)	170	22.5
	Secondary (9-12)	236	31.3
	Diploma	85	11.4
	Degree and above	93	12.3
Mother occupation	Housewife	325	43.1
	Self-employees	109	14.4
	Government employees	153	20.3
	Health professionals	11	1.5
	Non-governmental employees	29	3.9
	Farmer	12	1.6
	Merchant	98	13.0
	Other	17	2.2
Father occupation	Self-employees	286	37.9
	Government employees	196	26.0
	Health professionals	12	1.6
	Non-governmental employees	80	10.6
	Farmer	76	10.1
	Merchant	59	7.8
	Other	45	6.0

Knowledge about the HPV vaccine

Of all study participants, 264 (35.0%) of the school girls knew that the HPV vaccine prevents HPV infection, and 464 (61.5%) of the respondents knew that it prevents cervical cancer. More than half of the participants, 411 (54.5%), knew the Human Papillomavirus vaccine should be given before the first sexual intercourse, and 205 (27.2%) knew the HPV vaccine can be given to people who have had a sexual history. In addition, 243 (32.2%) and 117 (15.5%) of the respondents knew the recommended age and dose of the Human Papillomavirus vaccine, respectively (Table 4).

Table 4.

Knowledge about human papillomavirus vaccine among adolescent public high school girls aged 15-19 years in Arada sub city, Addis Ababa, Ethiopia, 2024.

Knowledge item’s	Frequency (%)
HPV infections are preventable
Yes	332 (44.0)
No	29 (3.9)
I do not know	393 (52.1)
Does the HPV vaccine prevent HPV infection?
Yes	264 (35.0)
No	28 (3.7)
I do not know	462 (61.3)
Does the HPV vaccine prevent cervical cancer?
Yes	464 (61.5)
No	38 (5.1)
I do not know	252 (33.4)
Should an HPV vaccine be given prior to the first sexual intercourse?
Yes	411 (54.5)
No	17 (2.3)
I do not know	326 (43.2)
Can the HPV vaccine be given to people who have had sex?
Yes	205 (27.2)
No	82 (10.9)
I do not know	467 (61.9)
Can the HPV vaccine be given to a woman who is already infected with HPV?
Yes	106 (14.0)
No	128 (17.0)
I do not know	520 (69.0)
What age range is recommended for vaccination against HPV infection?
9-14 years	243 (32.2)
I do not know	511 (67.8)
How many doses are recommended for an HPV vaccine?
Two doses	117 (15.5)
I do not know	637 (84.5)
Did you know the schedule for the HPV vaccine?
Yes	151 (20.0)
No	104 (13.8)
I do not know	499 (66.2)
What is the site of the administration of the HPV vaccine?
Upper arm	519 (68.8)
I do not know	235 (31.2)

Attitude towards the HPV vaccine

A total of 88.6% of the study participants agreed or strongly agreed that cervical cancer is a very severe disease. About HPV effectiveness, 67% of the participants agreed or strongly agreed that the HPV vaccine is effective in preventing cervical cancer. About safety concerns, 26.4% of the participants agreed or strongly agreed that female adolescents are afraid of the side effects of HPV vaccination (Table 5).

Table 5.

Attitude towards the HPV vaccine among adolescent public high school girls aged 15-19 years in Arada sub city, Addis Ababa, Ethiopia, 2024.

Attitude items	Strongly agree	Agree	Neutral	Disagree	Strongly disagree
Do you think female adolescents are susceptible to HPV infection?	41 (5.4%)	29 (3.9%)	67 (8.8%)	275 (36.5%)	342 (45.4%)
Do you think cervical cancer is a severe disease?	470 (62.3%)	198 (26.3%)	25 (3.3%)	19 (2.5%)	42 (5.6%)
Do you think the HPV vaccine is effective in preventing cervical cancer?	275 (36.5%)	229 (30.4%)	103 (13.6%)	70 (9.3%)	77 (10.2%)
Do you think the HPV vaccine is safe?	223 (29.6%)	241 (32.0%)	187 (24.7%)	55 (7.3%)	48 (6.4%)
Do you think being vaccinated with HPV reduces the risk of having an HPV infection?	210 (27.9%)	275 (36.5%)	142 (18.7%)	75 (10.0%)	52 (6.9%)
Do you think the HPV vaccine is not easily found?	93 (12.3%)	106 (14.1%)	116 (15.3%)	299 (39.7%)	140 (18.6%)
Do you think female adolescents are afraid of the side effects of HPV vaccination?	182 (24.1%)	192 (25.5%)	118 (15.6%)	165 (21.9%)	97 (12.9%)
Would health professionals’ counseling affect your decision as to whether or not to receive a vaccination?	280 (37.1%)	235 (31.1%)	114 (15.1%)	57 (7.6%)	68 (9.1%)
Do you think vaccinating against HPV would encourage starting sexual activity?	96 (12.7%)	63 (8.4%)	227 (30.1%)	174 (23.1%)	194 (25.7%)
Would receiving an HPV vaccination be perceived as having an STI?	86 (11.4%)	69 (9.2%)	184 (24.4%)	175 (23.2%)	240 (31.8%)

Uptake of the HPV vaccine

The proportion of school girls reported to have received the HPV vaccine was 55.3% (95% CI: 51.7%, 58.8%). Of these, 146 (35.0%) had only one dose and 230 (55.2%) had two doses. (Table 6).

Table 6.

Uptake of HPV vaccine among adolescent public high school girls aged 15-19 years in Arada sub city, Addis Ababa, Ethiopia, 2024.

Variable	Category	Frequency	Percent (%) (95% CI)
HPV vaccine uptake	Yes	417	55.3 (51.7, 58.8)
HPV vaccine uptake	No	337	44.7 (41.2, 48.3)
How many times	Once	146	35.0 (30.6, 39.7)
	Two times	230	55.2 (50.3, 59.9)
	I do not remember	41	9.8 (7.3, 13.1)

Factors related to uptake of the HPV vaccine

This study revealed that knowledge of the HPV vaccine and a positive attitude towards it were significantly associated with uptake of the HPV vaccine after controlling for selected variables. The odds of having good knowledge were 3.0 times higher [AOR=3.0, (95% CI: 2.2, 4.2)] among those who received the HPV vaccine compared with those who did not. The odds of having a positive attitude were 3.3 times [AOR=3.3, (95% CI:1.6, 6.9)] greater in those who received the HPV vaccine compared to those who did not receive the HPV vaccine (Table 7).

Table 7.

Factors associated with uptake of HPV vaccine among adolescent public high school girls aged 15-19 years in Arada sub city, Addis Ababa, Ethiopia, 2024.

Independent variables	HPV vaccine		COR (95% CI)	AOR (95% CI)	P-value
Independent variables	Received	Not received	COR (95% CI)	AOR (95% CI)	P-value
Age
15	57	61	1.2 (0.6, 2.0)	1.0 (0.4, 2.5)	0.951
16	103	73	1.6 (0.9, 2.9)	1.9 (0.9, 4.3)	0.080
17	126	78	1.9 (1.1, 3.3)	1.9 (0.9, 3.9)	0.061
18	100	89	1.3 (0.7, 2.3)	1.3 (0.7, 2.4)	0.446
19	31	36	1	1
Religion
Protestant	33	27	1	1
Orthodox	345	263	1.1 (0.6,1.8)	1.1 (0.6, 1.9)	0.804
Muslim	39	47	0.7 (0.4, 1.3)	0.7 (0.3, 1.5)	0.346
Grade level
9	89	69	1	1
10	96	95	0.8 (0.5, 1.2)	0.6 (0.4, 1.0)	0.061
11	110	75	1.1 (0.7, 1.7)	0.8 (0.4, 1.5)	0.485
12	122	98	1.0 (0.6, 1.5)	1.0 (0.5, 2.0)	0.948
Father’s educational level
Unable to read and write	26	20	1	1
Able to read and write	37	38	0.7 (0.4, 1.6)	0.6 (0.3, 1.3)	0.180
Primary (1-8)	55	63	0.7 (0.3, 1.3)	0.5 (0.2, 1.2)	0.128
Secondary (9-12)	157	126	1.0 (0.5, 1.8)	0.7 (0.3, 1.6)	0.420
Diploma	56	38	1.1 (0.6, 2.3)	0.9 (0.4, 2.1)	0.798
Degree and above	86	52	1.3 (0.6, 2.5)	1.0 (0.4, 2.3)	0.931
Mother’s educational level
Unable to read and write	31	38	1	1
Able to read and write	58	43	1.7 (0.9, 3.1)	1.5 (0.8, 3.0)	0.233
Primary (1-8)	92	78	1.4 (0.8, 2.5)	1.1 (0.6, 2.2)	0.209
Secondary (9-12)	130	106	1.5 (0.9, 2.6)	1.1 (0.6, 2.2)	0.773
Diploma	54	31	2.1 (1.1, 4.1)	1.3 (0.7, 2.9)	0.555
Degree and above	52	41	1.6 (0.8, 2,9)	0.8 (0.4, 1.9)	0.658
Mother occupation
Housewives	159	166	0.5 (0.2, 1.9)	0.4 (0.1, 1.8)	0.248
Self-employees	63	46	0.8 (0.2, 2.8)	0.5 (0.1, 1.8)	0.392
Government employees	93	60	0.9 (0.2, 3.2)	0.7 (0.2, 2.7)	0.584
Health professional	7	4	1	1
Non-governmental employees	14	15	0.5 (0.1, 2.2)	0.3 (0.1, 1.6)	0.162
Farmer	7	5	0.8 (0.1, 4.3)	0.9 (0.1, 5.9)	0.940
Merchant	64	34	1.1 (0.3, 3.9)	0.7 (0.2, 3.1)	0.687
Other	10	7	0.8 (0.2, 3.9)	0.5 (0.1, 3.0)	0.479
Father occupation
Self-employees	150	136	0.7 (0.4, 1.3)	0.7 (0.4, 1.5)	0.371
Government employees	117	79	0.9 (0.5, 1.7)	0.8 (0.4, 1.6)	0.452
Health professional	5	7	0.4 (0.1, 1.6)	0.3 (0.1, 1.2)	0.090
Non-governmental employees	48	32	0.9 (0.4, 1.9)	0.8 (0.4, 1.9)	0.690
Farmer	36	40	0.5 (0.3, 1.2)	0.6 (0.3, 1.5)	0.273
Merchant	33	26	0.8 (0.3, 1.7)	0.7 (0.3, 1.7)	0.426
Other	28	17	1	1
Knowledge about the HPV vaccine
Good	212	88	2.9 (2.1, 4.0)	3.0 (2.2, 4.2)	0.001
Poor	205	249	1	1
Attitude toward the HPV vaccine
Positive	405	306	3.4 (1.7, 6.8)	3.3 (1.6, 6.9)	0.001
Negative	12	31	1	1

Discussion

The objectives of the current study were to assess HPV vaccine uptake among adolescent public high school girls aged 15-19 years and the associated factors in Addis Ababa. Accordingly, the results showed that the prevalence of HPV vaccine uptake among adolescent public high school girls aged 15-19 years was 55.3%. It also showed that knowledge about the HPV vaccine and attitudes towards it were significantly associated with HPV vaccine uptake after controlling for other potential confounders.

The uptake of the HPV vaccine among adolescent public high school girls aged 15-19 years in the present study was similar to some studies conducted in Ethiopia.^16,21 However, there were studies that showed a lower uptake of the HPV vaccine in Ethiopia.^17,19,20 Variations in these findings might depend on factors such as study design, study subjects, and sample size. Both primary and secondary schools were involved in the Ambo study.¹⁷ Both public and private preparatory schools were involved in the Bahir Dar study.¹⁹ In Gambella, the study design was a community-based cross-sectional study.²⁰ A higher uptake was reported in other studies in Ethiopia.^22,23 The variation in the age of the study population can be attributed to the enhanced success. The variation might be due to the accessibility of the HPV vaccine. Lower uptake was reported in Uganda,¹³ which could be attributed to the definition of HPV vaccine uptake.

Statistically significant associations were observed between HPV vaccine uptake and knowledge of the HPV vaccine. The odds of uptake were 3 times higher among study participants with good knowledge than among those with poor knowledge, which is in line with many other studies conducted in Ethiopia and elsewhere.^19,21–23 The implication of the finding is that health education about the HPV vaccine should be strengthened to achieve universal knowledge and enhance uptake in the target population.

We also found a statistically significant association between uptake of the HPV vaccine and attitudes towards it. The odds of HPV vaccine uptake among adolescent high school girls aged 15-19 years with a positive attitude towards the HPV vaccine were higher among those who received the HPV vaccine. This positive association was also reported in earlier studies in Ethiopia and elsewhere^{12,13,19,21,22,41,42}

This study provides important information on the prevalence of HPV vaccine uptake among adolescent public high school girls aged 15-19 years and on factors related to uptake, which could inform tailored public health messages and interventions. However, this study also has limitations. First, the cross-sectional study design precludes determining the direction of the association between the independent variable (knowledge and attitude) and the outcome (HPV vaccine uptake). Second, there was a possibility of recall bias since the data were collected not immediately after vaccination activities.

Conclusions

The study found that half of adolescent public high school girls aged 15-19 years in the study area received the HPV vaccine. Adolescent public high school girls aged 15-19 years with good knowledge of the HPV vaccine and a positive attitude towards it were significantly more likely to receive the HPV vaccine.

Footnotes

Acknowledgments

We would like to thank the Arada sub-city Administration Education Office, school directors, staff, and study participants for their unreserved cooperation during the data collection.

ORCID iD

Aklilu Feleke Haile

Ethical considerations

The study was conducted in accordance with the Declaration of Helsinki and was approved by the Institutional Research Ethics Review Committee of the Addis Continental Institute of Public Health (Ref. No: ACIPH-IRERC/009/2023). Participants were also informed about confidentiality, voluntariness, and privacy procedures. A written informed consent form was sent to legally authorized representatives via potential participants/students for review and signature; only students who returned the signed informed consent form were enrolled in the study. In addition, assent was obtained from adolescent girls younger than 18 years, and written informed consent was obtained from adolescent girls aged 18 and 19 years. Participation was entirely voluntary, and participants retained the right to withdraw from the study at any time. The confidentiality of information was maintained by not writing the participants’ names and by granting data access only to the research team.

Author contributions

AFH conceived and designed the study, conducted the study, analyzed the data, and wrote the manuscript. YB conceived and designed the study, analyzed the data, and reviewed the manuscript. All authors contributed to the article and approved the submitted version.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.*

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