PERCEPTION AND ACCEPTANCE OF HPV VACCINATION AMONG ADOLESCENT GIRLS IN PRIMARY HEALTH CENTRES IN KANO MUNICIPAL, KANO STATE.

CHAPTER ONE

ABSTRACT

Background: Human papillomavirus (HPV) is the most common sexually transmitted infection globally and the primary aetiological agent of cervical cancer, which ranks as the fourth most common cancer among women worldwide and the second most common cancer among Nigerian women. HPV vaccination is one of the most efficacious preventive interventions against cervical cancer, yet uptake remains critically low in northern Nigeria due to complex socio-cultural, religious, and structural barriers. Kano Municipal, as the largest urban local government area in Kano State, provides an instructive setting for examining the interplay of these factors among adolescent girls accessing primary health centres.

Objective: This study assesses the perception and acceptance of HPV vaccination among adolescent girls attending primary health centres in Kano Municipal, Kano State.

Methods: A descriptive cross-sectional design was adopted. Using systematic random sampling, 380 adolescent girls aged 10–19 years attending primary health centres in Kano Municipal were recruited. A pretested structured questionnaire was administered. Data were analysed with SPSS version 26, using chi-square and logistic regression to identify predictors of HPV vaccine acceptance.

Expected Findings: It is anticipated that knowledge of HPV and its vaccine will be low, with perceptions strongly influenced by religious norms and parental authority. Acceptance rates are expected to be modest, with parental consent, community health worker engagement, and educational level emerging as significant predictors.

Conclusion: Culturally sensitive, community-embedded communication strategies and strong stakeholder engagement with religious leaders, parents, and schools are essential to improving HPV vaccine perception and acceptance in Kano Municipal.

Keywords: HPV vaccination, cervical cancer, adolescent girls, perception, acceptance, primary health centres, Kano State, northern Nigeria.

1.0 INTRODUCTION

1.1 BACKGROUND TO THE STUDY

Cervical cancer is a devastating public health problem in sub-Saharan Africa, and is preventable in the majority of cases. World Health Organization (WHO) estimates indicate that globally, some 604,000 new cervical cancer cases were identified and 342,000 people died of cancer of the cervix in 2020, of which more than 90% of deaths occurred in low- and middle-income countries (LMICs) (WHO, 2022). Nigeria is disproportionately affected by cervical cancer, as it is estimated that 12,000 new cases of the disease occur annually, accounting for more than 8,000 cancer-related deaths among Nigerian women, compared to breast cancer which is the number one killer (Ferlay et al., 2021). HPV vaccines are the most important primary prevention strategy against cervical cancer available, responsible for an estimated 70% of global cases, especially of HPV vaccine types 16 and 18 (WHO, 2022).

Global efforts to eradicate cervical cancer through HPV vaccination started in 2020 with the target of 90% HPV vaccination coverage of girls aged 15 by 2030 set by the WHO. It is difficult to attain this goal in Nigeria, especially in the northern states like Kano. Progress with the state-level HPV vaccination programme, with support from Gavi, the Vaccine Alliance and the National Primary Health Care Development Agency (NPHCDA), is incremental but coverage data from the North West geopolitical zone remain among the lowest in the country overall (NPHCDA, 2022). Socio-cultural context in Kano State marked by high levels of Islamic religious values, high levels of girl-child marriage, low levels of female literacy, and strong gatekeeping systems within the community create multiple layers of social and institutional complexity that require careful navigation of the vaccination programmes for adolescent girls (Braka et al., 2021).

Often, adolescent girls and caregivers' perceptions of HPV vaccination in the northern part of Nigeria are influenced by misinformation, such as claims that HPV vaccines are linked to infertility, promote sexual activity, or conflict with religious guidance (Abdullahi et al., 2020). Social media and community rumour networks exacerbate these misconceptions, which create important structural obstacles to vaccine uptake that can't be cleared with an approach to supply alone. Thus, to design targeted evidence-based vaccine promotion strategies, it is important to understand the specific perceptions that adolescent girls have in the primary health centre level in Kano Municipal.

This study is aimed to generate that evidence, which explores the spectrum of perceptions adolescent girls may have towards HPV vaccines (positive, neutral, and negative), and factors associated with HPV vaccination uptake at the individual, household, and community levels.

HPV vaccines were first licensed worldwide in 2006 with the quadrivalent vaccine HPV4 (Gardasil), and then the bivalent vaccine HPV2 (Cervarix) was licensed in 2009. By 2022, more than 120 countries had made HPV vaccination a part of the national immunization programs (WHO, 2022). Nigeria launched HPV vaccination in the national immunisation programme (NIP) in 2023 after achieving successful pilot programmes in selected States including Kano State through a pilot project of HPV vaccine implementation that led to valuable learning experiences (Braka et al., 2021).

The HPV vaccination demonstration project in Kano state, covering girls in Primary School, JSS1, from 2013 to 2015, showed higher vaccination coverage among urban girls (64%) compared to rural and peri-urban girls (Braka et al., 2021). These are the main barriers that were cited in that programme – lack of knowledge among parents, religious concerns, concern about side effects, and of course factors related to the lack of smooth running of the programme at the facilities. Further contemporary research in Kano and neighbouring states in the North also shows mixed sentiments about HPV vaccination, with high percentages of both caregivers and adolescents being vaccine hesitant (Abdullahi et al., 2020; Abiodun et al., 2022).

Primary health centres (PHCs) are key to Nigeria's vaccination strategy as the first point of vaccination service delivery. For the adolescent girl population, in particular, PHCs are the primary interface between the formal health system and the girl population in Kano, especially for the girls who are not in school, which forms a significant proportion of the girl population in Kano, with documented gender gap in enrolment in secondary school as per UNESCO (2021). However, there is limited HPV vaccination attitude/acceptance data at the PHC level, nor has there been a systematic study on the dynamics of the Kano Municipal context (in terms of high urban population, high concentration of Quranic schools and diverse socio-economic profile) in relation to HPV vaccine uptake.

HPV vaccine acceptance studies across the world in LMICs have identified some consistent factors associated with acceptance: educational level, trust in health systems, peer and community support, health worker recommendations, and parental support (Bruni et al., 2021). On the other hand, exposure to misinformation, media framing, weak health system relationships and lack of male and religious leader endorsement are linked to vaccine hesitancy. The results presented above from the global literature are used to examine the vaccine perception and acceptance in the Kano Municipality context, while acknowledging that social and cultural factors may have specificities in the local context impact vaccine perception and acceptance among the study population.

1.2 STATEMENT OF THE PROBLEM

Although HPV vaccine has proven its effectiveness in preventing cervical cancer, and is available under the Nigerian national immunisation programme, adolescent girls in Kano Municipal have not had any vaccine uptake. Religious conservatives, parental gatekeeping, misinformation and poor health literacy combine in complex ways to create a multi-dimensional barrier to vaccine acceptance at the primary health centre (PHAK) level in Kano Municipal.

The available data on HPV vaccine perceptions in northern Nigeria mostly focuses on adult women or school-based surveys with minimal representation of adolescent girls attending primary health centres in Kano Municipal. The evidence gap prevents PHC staff, such as nurses, midwives and community health workers, from drawing on the particular perceptions held by their adolescent client when reaching out to them in their communication and counselling. Otherwise, vaccination sessions could simply be another chance at presenting this issue in the same way, which could exacerbate the existing hesitancy. Thus, this study seeks to address the pressing need for adolescent specific perception and acceptance of HPV vaccination for the adolescent population in PHC access to PHC-level data.Therefore, this study was conducted to fill the current gap of adolescent specific perception and acceptance of HPV vaccination for the adolescent population in PHC level access to PHC-level data.

1.3 OBJECTIVES OF THE STUDY

The general objective is to assess the perception and acceptance of HPV vaccination among adolescent girls attending primary health centres in Kano Municipal, Kano State.

Specific objectives are to:

1. Assess the level of knowledge of HPV and HPV vaccination among adolescent girls attending PHCs in Kano Municipal.
2. Determine the prevailing perceptions of HPV vaccination among the study population.
3. Assess the level of HPV vaccine acceptance among adolescent girls attending PHCs in Kano Municipal.
4. Identify the socio-cultural, religious, and structural factors influencing HPV vaccine acceptance among respondents.
5. Determine the relationship between sociodemographic characteristics and HPV vaccine acceptance among the study participants.

1.4 RESEARCH QUESTIONS

1. What is the level of knowledge of HPV and HPV vaccination among adolescent girls attending PHCs in Kano Municipal?
2. What are the prevailing perceptions of HPV vaccination among adolescent girls in the study population?
3. What is the level of HPV vaccine acceptance among adolescent girls attending PHCs in Kano Municipal?
4. What socio-cultural, religious, and structural factors influence HPV vaccine acceptance among respondents?
5. Is there a significant relationship between sociodemographic characteristics and HPV vaccine acceptance among adolescent girls in Kano Municipal?

1.5 RESEARCH HYPOTHESES

H01: There is no significant relationship between knowledge of HPV and vaccine acceptance among adolescent girls attending PHCs in Kano Municipal.

H02: There is no significant association between religious beliefs and perception of HPV vaccination among adolescent girls in the study population.

H03: There is no significant relationship between parental educational level and HPV vaccine acceptance among adolescent girls attending PHCs in Kano Municipal.

1.6 SIGNIFICANCE OF THE STUDY

The findings of this study will be of direct relevance to multiple stakeholders in the HPV vaccination ecosystem in Kano State and nationally. For PHC-level health workers including nurses, midwives, and community health extension workers the study provides actionable intelligence on the specific perceptions that drive vaccine hesitancy among their adolescent clients, enabling more targeted and effective counselling approaches. For the Kano State Ministry of Health and the NPHCDA, the findings will inform the design of culturally responsive HPV vaccine communication campaigns, including the development of messages endorsed by religious leaders and delivered through trusted community channels.

For the academic and public health research community, this study adds to the limited literature on HPV vaccination perceptions among PHC-attending adolescent girls in urban northern Nigeria, providing a foundation for larger multi-state studies. For advocacy organisations working on cervical cancer prevention in Nigeria, the findings offer empirical evidence to support calls for increased government investment in HPV vaccination infrastructure, demand-generation activities, and community engagement in northern states. Ultimately, by contributing to improved HPV vaccine uptake, the study supports Nigeria's commitment to the WHO global strategy for cervical cancer elimination.

1.7 SCOPE OF THE STUDY

This study is confined to adolescent girls aged 10–19 years attending primary health centres in Kano Municipal Local Government Area, Kano State. It focuses specifically on perceptions and acceptance of HPV vaccination, including knowledge of HPV as a disease, awareness of the HPV vaccine, attitudes toward vaccination, and self-reported or proxy-reported vaccination status. The study does not extend to other vaccines, to other age groups, or to health facilities outside the primary health centre level in Kano Municipal. It does not include male adolescents, though their role as future sexual partners is acknowledged in the contextual discussion.

1.8 LIMITATIONS OF THE STUDY

The study acknowledges several potential limitations. Social desirability bias may affect responses, particularly in a socially conservative context where adolescent girls may underreport behaviours or attitudes that they perceive as inconsistent with community norms. Parental or guardian presence during data collection, while required for ethical informed consent in some cases, may influence the candour of adolescent responses. The cross-sectional design precludes the establishment of causal relationships between identified factors and vaccine acceptance. Restriction of the study to PHC attendees may exclude girls with very limited health system contact, who may represent the highest-risk group for non-vaccination. These limitations will be mitigated through careful data collection protocols, private interview settings, and transparent reporting of findings.

1.9 DEFINITION OF TERMS

Human Papillomavirus (HPV): A group of more than 200 related viruses, of which at least 14 are oncogenic (cancer-causing), transmitted primarily through sexual contact. High-risk HPV types 16 and 18 are responsible for the majority of cervical cancers globally (WHO, 2022).

HPV Vaccination: The administration of a prophylactic vaccine targeting high-risk HPV genotypes to prevent HPV infection and its sequelae, including cervical cancer, genital warts, and other HPV-related cancers (Bruni et al., 2021).

Perception: The way in which an individual interprets, understands, and evaluates a health intervention in this case, HPV vaccination based on their existing knowledge, beliefs, cultural values, and prior health experiences (Abdullahi et al., 2020).

Acceptance: The willingness of an adolescent girl or her parent/guardian to receive or consent to the receipt of HPV vaccination, as determined through self-report or behavioural intent measures (Braka et al., 2021).

Adolescent Girl: In this study, a female individual between the ages of 10 and 19 years, consistent with the WHO definition of adolescence (WHO, 2022).

Vaccine Hesitancy: A delay in acceptance or refusal of vaccination despite availability of vaccination services, defined by the WHO Strategic Advisory Group of Experts (SAGE) on Immunisation Working Group as influenced by factors including complacency, convenience, and confidence (WHO, 2019).

Primary Health Centre (PHC): A government-operated first-level health facility providing basic preventive, promotive, and curative healthcare services, including immunisation, to community members in a defined catchment area (NPHCDA, 2022).

Misinformation: False or inaccurate information about HPV and HPV vaccination, regardless of intent, that influences health perceptions and vaccination decisions (Suarez-Lledo & Alvarez-Galvez, 2021).

REFERENCES

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