Uptake of human papilloma virus vaccine and its determinants among females in East Africa: a systematic review and meta-analysis

Cervical cancer is the fourth most common malignant tumor among women, and globally, about 604,127 new cases and 34,1831 deaths occurred in the year 2020 [1]. Of the total global deaths, about 90% occurred in low- and middle-income countries [2]. In developing countries, cervical cancer accounts for about 12% of all female cancers [3]. In Africa, it is the second form of cancer, with an incidence of 117,316 cases, and the total number of deaths by the year 2020 was 76,745 [4]. It is also the most common cause of death among women in sub-Saharan African countries [5]. East African countries contribute the highest numbers of incidence and death rates, at 27.6 and 42.7 per 100,000, respectively [6].

The major responsible cause of cervical cancer is the human papilloma virus. Human papilloma virus (HPV) 16 and 18 account for about 70% of all forms of cervical cancer [7]. Of all forms of HPV infection, about 10% advanced to precancerous lesions [8, 9]. Globally, about 11–12% of apparently healthy women have lived with HPV [10]. The incidence, prevalence, and mortality of cervical cancer are significantly reduced by the HPV vaccine, which can reduce cervical cancer-related death by 80% [11, 12]. According to the World Health Organization’s recommendation, vaccinating girls aged 9–14 is extremely effective when it takes place before sexual initiation and before HPV infection [13]. Of the three HPV vaccines, two of them, such as Gardasil and Cervarix, are accessible globally to prevent HPV-16 and HPV-18 strains [8]. Even though significant achievements are observed around the globe, low-income countries have encountered the difficulty of getting the HPV vaccine [14, 15]. In spite of the fact that the World Health Organization (WHO) recommends the introduction of the HPV vaccine for low-income countries, there is unequal distribution of the HPV vaccine across the countries because of differences in socioeconomics, culture, and knowledge about the HPV vaccine uptake [16]. According to the WHO report, the coverage of the HPV vaccine is higher in high-income countries (79%) than in upper-middle-income countries (58%), middle-income countries (26%), and low-income countries (21%) [17]. As the evidence showed, educational status [18], older age [19‐21], ethnicity [18, 19, 22] and medium social economic status [20, 21] were the determinants of HPV vaccine uptake. Even though the burden of HPV-related cervical cancer is high, there is no conclusive and national-level evidence about the prevalence of HPV vaccine uptake and its determinants in East Africa. Therefore, this study was aimed at assessing the pooled prevalence of HPV vaccine uptake and its determinants among females in East African countries using a systematic review and meta-analysis.

In the current systematic review and meta-analysis, an attempt has been made to assess the pooled prevalence of HPV vaccine uptake and its determinants in East Africa. Thus, the pooled prevalence of HPV vaccine uptake in East Africa was 35% (95% CI: 26–45%). The findings were consistent with a systematic and meta-analysis study conducted in Ethiopia’s (42.05%) [42]. But it was lower than the global strategic plan by 2030 (90%) [43], the global estimate of HPV vaccine coverage (77%) [44], a study conducted in 14 high-income countries among girls aged 13–19 years (83%) [45], in India (66%) [45], and in the United states of America (62.8%) [46]. The possible reason for this difference may be because of the variation in access to the HPV vaccine, the difference in socioeconomic status across the countries, the discrepancy in commitment to expand, and the difference in knowledge about the HPV vaccine. The other possible reason may be that the effects of COVID-19 significantly affect health services, including HPV vaccination practice. Similarly, in the current study, the lowest pooled prevalence of HPV vaccine uptake was reported after the COVID-19 pandemic. This implies that the COVID-19 pandemic strongly affects health service activities like health education about the HPV vaccine and the routine vaccination practice of the HPV vaccine. In contrast, the pooled prevalence of the HPV vaccine in East Africa was lower than in a study conducted in Sub-Saharan African countries (20%) [47]. This may be due to the difference in the study period. Because the level of awareness about the HPV vaccine and access to the vaccine can vary over time. Furthermore, a subgroup analysis by age category of the participant also revealed that the pooled prevalence of HPV vaccine uptake was higher among adolescents (37%; 95% CI: 26–47%). This might be associated with the fact that the majority of countries give attention and put an effort into the vaccination of adolescent girls. Countries have tried to expand school-based immunization campaigns among adolescents, which might be a possible justification for an increase in the adolescents’ vaccination rate.

Regarding the significant factors associated with the uptake of the HPV vaccine, having good knowledge about the HPV vaccine positively affected the uptake of the HPV vaccine. This finding was supported by a study of systematic and meta-analyses among teenagers [48], in Italy [49], in China [50] and Ethiopia [42]. This may be because knowledge is the key to taking an important prevention strategy. Knowledge about HPV infection and the HPV vaccine provides an important evidence-based decision for HPV vaccine uptake. Additionally, females who had ever heard about the HPV vaccine were more likely to uptake it, as supported by a study conducted in China and Malaysia [51, 52]. The possible explanation may be that females who have ever heard about the HPV vaccine could be the starting point for the uptake of the HPV vaccine, or it could provide an opportunity to have the most important messages about the benefit and the appropriate age of vaccination. In return, it could give them the confidence to take appropriate decisions.

Another factor that influences the uptake of the HPV vaccine is the attitude towards the HPV vaccine. Thus, females who had a positive attitude towards the HPV vaccine were more likely to uptake the HPV vaccine than those who had a negative attitude towards the HPV vaccine. This finding was supported by a study conducted using systematic and meta-analyses [42, 48]. This might be associated with the fact that a female’s healthy lifestyle can be influenced by their attitude. The most discouraging factor of female practice is generated by their negative attitude. Females reacting negatively to a stimulus about the HPV vaccine may reduce their motivation to take the vaccine. Another piece of evidence also showed that a negative attitude is the most common barrier to the uptake of the HPV vaccine [53].

The residence was also a significant factor in the uptake of the HPV vaccine. Females who were from urban residences were more likely to uptake the HPV vaccine than rural residents. This was supported by a systematic and meta-analytic study conducted in Ethiopia [42]. This could be justified by the fact that female urban residents are more likely to access health information and health services than rural residents. Additionally, females whose mothers’ educational status was above college were more likely to uptake the HPV vaccine than those without formal education. This was supported by a study conducted in China [54]. This could be justified by the fact that educated mothers have more information, knowledge, and socioeconomic status than uneducated mothers, which enables them to advise and encourage their children to uptake the HPV vaccine.

Females from the middle wealth index family were more likely to uptake the HPV vaccine than from the poorest wealth index family. This was supported by a study conducted in the United States of America (USA) [55]. This may be because economic status is an important input (enabling factor) for the uptake of health services, better information access, and a healthier lifestyle. The other possible justification is that socioeconomic status can provide and encourage positive health behavior [39].

Family size was also an important factor in the uptake of the HPV vaccine. Females whose family size was nine and above were less likely to uptake the HPV vaccine than those whose family size was less than nine. This finding was agreed upon by a study conducted in Nigeria [56]. This is because large family sizes negatively affect the utilization of health services [56].

In the systematic review (qualitative narration), the availability of vaccines at the site of vaccination was a positive predictor of HPV vaccine uptake [34]. This finding was agreed upon by a study conducted in South Michigan [57]. This is because adequate availability of vaccine at the site of vaccination improves the vaccine uptake from 11% before availability to 16% after availability [34]. Even if the availability of vaccines at the site of vaccination is crucial for the uptake of the HPV vaccine, in itself, it is not enough for the sustainable improvement of HPV vaccination coverage. It also needs adequate resources to support the program, health education and counselling services, health professional capacity building, proper or fair distribution of the vaccine, community outreach vaccinations, and the availability of promotion about the HPV vaccine. Furthermore, females who had family or guardian support to receive the HPV vaccine were more likely to uptake the HPV vaccine than those who had no family or guardian support [41].. This was supported by a study conducted in the USA and Victoria [58, 59]. This could be because those who are supported by their family or guardian can get adequate knowledge about the HPV vaccine, have a favorable attitude towards HPV vaccine uptake, and can provide an important step in deciding the uptake of the HPV vaccine. Additionally, most of the time, adolescents’ decisions rest on their family or guardian, and thus family support offers a crucial factor in expanding vaccination practice. The limitation of the current study was that articles without full text were excluded, which may affect the actual pooled effect.

As compared to the global strategic plan, the pooled prevalence of HPV vaccine uptake in east Africa was low. The uptake of HPV vaccine was higher among adolescents than youths. Knowledge about the HPV vaccine, attitude towards the HPV vaccine, ever hearing about the HPV vaccine, residence, mother’s educational status, mother’s occupational status, wealth index, and family size were the significant determinants of HPV vaccine uptake. Therefore, we recommend focusing on awareness creation and behavioral change to expand the uptake of vaccines in East Africa.