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Year : 2019  |  Volume : 22  |  Issue : 9  |  Page : 1286-1291

Appraisal of willingness to vaccinate daughters with human papilloma virus vaccine and cervical cancer screening uptake among mothers of adolescent students in Abakaliki, Nigeria

1 Department of Community Medicine, Ebonyi State University; Department of Community Medicine, Alex Ekwueme Federal University Teaching Hospital, Abakaliki, Ebonyi State, Nigeria
2 Department of Community Medicine, Alex Ekwueme Federal University Teaching Hospital, Abakaliki, Ebonyi State; Nigeria Field Epidemiology and Laboratory Training Program, Asokoro Abuja, Nigeria
3 Department of Nursing, Ebonyi State University, Abakaliki, Ebonyi State, Nigeria
4 Department of Paediatrics, Alex Ekwueme Federal University Teaching Hospital, Abakaliki, Ebonyi State, Nigeria
5 Department of Community Medicine, Alex Ekwueme Federal University Teaching Hospital, Abakaliki, Ebonyi State, Nigeria
6 Department of Obstetrics and Gynaecology, Alex Ekwueme Federal University Teaching Hospital, Abakaliki, Ebonyi State, Nigeria

Date of Acceptance16-May-2019
Date of Web Publication6-Sep-2019

Correspondence Address:
Dr. B N Azuogu
Department of Community Medicine, Ebonyi State University, Abakaliki
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/njcp.njcp_452_18

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Background: By the end of 2017, human papillomavirus (HPV) vaccine had been introduced in 80 countries, but Nigeria proposes introducing the vaccine into her routine immunization program from late 2020 or early 2021. The current mode of HPV access in the country is through out-of-pocket purchase with only 1.4% of adolescent girls being vaccinated. Cervical cancer has remained the second highest cancer among women in Nigeria, and the incidence rate is significantly higher than the global rate. This study assessed the factors associated with HPV awareness and willingness to vaccinate daughters among mothers of female secondary school students in Abakaliki. Materials and Methods: A cross-sectional study was carried out among 290 mothers of female students selected through multistage sampling technique using a pretested self-administered questionnaire. Data were analyzed with Epi Info™ version 7. Results: The mean age of the mothers was 42 ± 8 years, and 72.8% attained at least secondary education, while 37.2% were traders. Their awareness of HPV and uptake of cervical cancer screening were low, 42.8% and 9%, respectively. Although 89.1% were willing to vaccinate their daughters, only 6.9% of their daughters had ever received HPV vaccine. Lack of awareness on HPV vaccine and cost of purchase were the most cited reasons for low vaccine uptake. Education, screening status, mother–daughter vaccination status, and willingness to encourage others on HPV vaccine for daughters were significantly associated with HPV awareness. Conclusion: Most of the mothers were willing to vaccinate their daughters with HPV vaccine, but they lack awareness and the financial resources for the access. There is an urgent need for vigorous enlightenment campaigns on HPV vaccine and cervical cancer screening. Adding HPV vaccine in the routine immunization program will improve universal access and address financial concerns.

Keywords: Adolescent students, appraisal, cervical cancer screening, human papillomavirus vaccination, willingness

How to cite this article:
Azuogu B N, Umeokonkwo C D, Azuogu V C, Onwe O E, Okedo-Alex I N, Egbuji C C. Appraisal of willingness to vaccinate daughters with human papilloma virus vaccine and cervical cancer screening uptake among mothers of adolescent students in Abakaliki, Nigeria. Niger J Clin Pract 2019;22:1286-91

How to cite this URL:
Azuogu B N, Umeokonkwo C D, Azuogu V C, Onwe O E, Okedo-Alex I N, Egbuji C C. Appraisal of willingness to vaccinate daughters with human papilloma virus vaccine and cervical cancer screening uptake among mothers of adolescent students in Abakaliki, Nigeria. Niger J Clin Pract [serial online] 2019 [cited 2022 Nov 29];22:1286-91. Available from:

   Introduction Top

Human papillomavirus (HPV) is a vaccine-preventable sexually transmitted viral infection of the reproductive tract, and now a well-established cause of cervical cancer. By the end of 2017, HPV vaccine was introduced in 80 countries.[1],[2] Nigeria proposes introducing the vaccine into her routine immunization program from late 2020 or early 2021, given that that the country's cervical cancer incidence rate (29 cases per 100,000 women) is significantly higher than the global rate of 14 cases per 100,000 women.[3]

The Vaccine Alliance (GAVI) is currently supporting countries in the acceleration of HPV vaccine programs by fostering political and grassroots awareness on the critical role of HPV vaccination in protecting about 40 million girls from cervical cancer by 2020, and averting an estimated 900,000 deaths.[4] Cervical cancer is the second most common cancer in women worldwide, accounting for more than 270,000 annual deaths with more than 85% of these deaths occur in low- and middle-income countries.[5],[6] Despite that cervical cancer is preventable and curable especially when detected early, over 14,000 Nigerian women are diagnosed yearly with the disease and 8240 of them die annually from it.[2]

The World Health Organization (WHO) recommended vaccination against HPV in adolescent girls aged 9–13 years, combined with regular screening in women over age 30.[5] In 2009, the WHO issued a position paper recommending that routine HPV vaccination be included in national immunization programs in settings where prevention of cervical cancer or other HPV-related diseases constitute a public health priority.[7] Through GAVI support, the poorest countries now have access to HPV vaccines for as little as US$ 4.50 per dose against over US$ 100/dose in high-income countries. In addition, the WHO has recommended switching from three doses to two doses schedule to facilitate country roll-outs and reduce costs.[4] However, HPV vaccination access in Nigeria is restricted to out of pocket purchase mainly in private health-care facilities. Studies have shown that adopting a national HPV vaccination combined with opportunistic cervical cancer screening can be cost-effective in Nigeria.[8] HPV vaccination remains low in Nigeria as only 1.4% of adolescent girls have reportedly received the vaccine.[9]

Previous studies have demonstrated the need to increase awareness about HPV infection, cervical cancer, and HPV vaccination among targeted audience of parents/guardians as they are the critical decision-makers for vaccine delivery to children.[10],[11] Nonacceptability of the HPV vaccine among mothers has been associated with a lack of adequate information.[12],[13] Levels of awareness/knowledge of cervical cancer and its prevention have also been found to vary across populations and geographical settings. In some developed settings, mothers have been found to have low awareness about cervical cancer and HPV [12],[14],[15],[16],[17],[18],[19] while some other studies found mothers to have adequate knowledge.[13],[20] Poor awareness about HPV/HPV vaccines has been documented among mothers in Nigeria.[21],[22],[23] In spite of the low awareness, most studies have shown that majority of Nigerian mothers were willing to have the HPV vaccine administered to their adolescent daughters.[9],[21],[23],[24],[25]

Cost of the vaccine, lack of awareness/knowledge, lack of access and fear that vaccination may encourage sexual promiscuity are commonly cited reasons for nonacceptability of adolescent daughter's vaccination with HPV vaccine among Nigerian mothers. Other determinants of HPV vaccination decisiveness include income level, understanding that cervical cancer is preventable, knowledge of sexually transmitted infection and perception of daughter's susceptibility to HPV infection.[9],[21],[23],[24],[25] Since mothers can play a pivotal role in preventing cervical cancer for themselves and their daughters, assessment of their level of awareness of HPV, willingness to vaccinate their adolescent daughters with the vaccine, and uptake of cervical cancer screening were undertaken to generate context-specific information, education, and communication strategies that could enhance successful HPV vaccination programme in our setting.

   Materials and Methods Top

A descriptive cross-sectional study of 290 mothers of senior secondary school students was conducted from a list of all the twenty-two female secondary schools in Abakaliki education zone of Ebonyi State obtained from the State Ministry of Education. Using multistage sampling technique, the schools were first stratified into four groups according to 4 axes of the zone. In the second stage one school was randomly selected from each axis by balloting. With proportionate allocation, a minimum of 60 mothers were interviewed in each of the selected schools by consecutive recruitment as they arrived during Parents–Teachers Association meeting until the allocated number was reached. The sample size was calculated using the Leslie Fischer's formula: n = Z 2 pq/d 2.[26]

Ethical approved was obtained from the Research and Ethics Committee of Federal Teaching Hospital Abakaliki, and written informed consent was obtained from the respondents, while anonymity of participants' data and confidentiality of the information collected was maintained. The study was conducted in February 2018 and lasted for 3 weeks. Only mothers living with their daughters and who had resided in the study area for up to 1 year at the time of the study were included.

Semi-structured self-administered pretested questionnaire was used to elicit information from the mothers on their sociodemographic characteristics, awareness about HPV infection, cervical cancer, and willingness to HPV vaccination for their daughters. Willingness to allow their daughters for HPV vaccination was assessed after a health talk on HPV as a vaccine-preventable STI and its association with cervical cancer.

Data were analyzed using EpiInfo™ software version 7 (designed by Centers for Disease Control and Prevention). The general characteristics of the study population were determined using descriptive statistics. The relationship between awareness of cervical cancer screening and other factors was assessed using Chi-square at significance level of 0.05.

   Results Top

In [Table 1], the mean age of the mothers was 42 ± 8 years. Majority (45.2%) of the mothers were aged 40–49 years. Almost 90% were married, and 73.8% of the respondents attained at least secondary education. They were predominantly traders (37.2%) and civil servants (23.5%). Majority (76.2%) of the mothers earned 40,000 naira or less monthly. About 54% of their first daughters were aged 10–19 years.
Table 1: Sociodemographic characteristics of the respondents (n=290)

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[Table 2] shows that the awareness of HPV as an STI that is associated with cervical cancer was poor as only 42.8% of the women had heard about it. The cervical cancer screening among the study population was equally poor, <10% of women had ever screened for cervical cancer, and only 2.4% has ever received vaccination against HPV infection.
Table 2: Awareness of human papillomavirus and prevalence of vaccination among the respondents (n=290)

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[Table 3] reveals that only 6.9% of their daughters had received vaccination for HPV. The main reasons adduced by the mothers for not giving their daughters HPV vaccine include not being aware of HPV vaccine (74.6%), not knowing where to access it (9%), and cost of the vaccine (9%).
Table 3: Participants willingness to allow their daughters to receive human papillomavirus vaccine

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Awareness of HPV vaccine was associated with screening for cervical cancer, vaccine uptake by the mothers and their daughters, and encouraging other mothers to vaccinate their girl child. The level of education was associated with awareness of cervical cancer screening [Table 4].
Table 4: Factors associated with awareness of human papillomavirus among the respondents

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   Discussion Top

The low level of awareness of HPV as an STI associated with cervical cancer found among the respondents despite that most of them had up to secondary level education is worrisome. This could have far-reaching implications on their ability to educate their daughters on sexual practices pertinent for the prevention of HPV infection since some of the adolescents may have been sexually active and would benefit from STI control information from the mothers.[27] Mothers with a higher education level have been reported to have increased awareness and knowledge of HPV infection.[15] Contrary to our finding, studies conducted in different parts of Nigeria found that lower proportions (9%–27.9%) of mothers with awareness of HPV infection.[21],[22],[23],[28] It is noteworthy that these studies were mostly conducted in urban cities in Nigeria, and thus highlight the need to increase sensitization on HPV infection and prevention of cervical cancer through HPV vaccination. Lower proportions of awareness on HPV have also been documented among mothers in Morocco and China, 4.7% and 19.3%, respectively.[12],[15] Conversely, other studies in the United States reported that 45%–63% of mothers were aware of HPV.[11],[19],[20] These higher proportions could be because HPV-associated awareness creation and vaccination have long been on the routine immunization program in the US as against the current situation in Nigeria and other developing countries.

Educational status, screening for cervical cancer, mother–daughter HPV vaccination status, and willingness to encourage other mothers on HPV vaccination were significantly associated with maternal awareness of HPV. Similarly, maternal educational status and English writing proficiency have been found to be associated with awareness on HPV from other studies.[15],[19],[21] In addition, studies have reported statistically significant associations between maternal HPV awareness and daughter's age, and maternal income and occupation.[15],[20]

About 9% of the mothers in this study had been screened for cervical cancer. This is in contrast to other studies in Ebonyi State, where 0.6% of women reported having screened for cervical cancer.[29] Poor awareness on cervical cancer and where to access screening services may explain the lower uptake of cervical cancer screening recorded in the previous study.

In our study, majority of the mothers (89.1%) were willing to vaccinate their daughters with the HPV vaccine. Such high levels of willingness to vaccinate adolescent daughters have been reported from similar studies among mothers in Nigeria.[9],[21],[23],[24],[25],[28] Studies among Indian, Cambodian American, Danish, and South Korean mothers also showed that majority of the mothers surveyed were willing to allow their daughters receive the HPV vaccine.[13],[18],[30],[31] Parental willingness (particularly the mothers) to support their adolescent daughter's vaccination in this context is important not only because the girls need their parents for vaccination decisions but also because they need their financial support. This is particularly important in Nigeria where HPV vaccine is not yet among the vaccines given free of charge in the National Programme on Immunization.[18],[22] In addition, 77.1% of the mothers in our study were willing to encourage other mothers to vaccinate their daughters against HPV infection, as found in another study.[21] Conversely, less than a third of mothers were willing to have their daughters vaccinated in some other studies, and fear of side effects and cost concerns were the commonly cited reasons for low acceptability of the vaccine.[12],[14],[15] This is also supported by findings from other studies.[21],[23],[24]

In this study, only a small proportion of mothers (6.9%) reported that their daughter had ever received HPV vaccine, and lack of awareness of the vaccine was the most frequently cited reason for nonvaccination. This is similar to a South Korean study where 7.2% of mothers reported HPV vaccination for their daughters, but in contrast to 32.6% documented among Cambodian American mothers.[18],[32] Apart from poor awareness, the appalling low vaccination rates seen in our study and others are largely due to the high prices of the vaccines in low- and middle-income countries.[12],[21],[22],[28] Mothers of adolescent girls have advocated the incorporation of HPV vaccination into routine immunization program.[24] Given the global commitment to universal health coverage with equitable access as a core underpinning, there is a need to include this vaccine in national immunization schedule so as to facilitate access by the poor.

The study had some strength as it also assessed the willingness of mothers to be agents of change to influence other mothers on HPV vaccination for their daughters. It is also one of the few studies on this topic in South-eastern Nigeria, which is socioeconomically and geographically different from other regions of the country.

   Conclusion Top

Although literacy level was relatively high, the level of awareness of cervical cancer, HPV, and vaccination against HPV was generally poor. The practice of cancer screening and uptake of vaccination among the study population was even poorer. There was however great enthusiasm among the mothers to allow their daughters to be vaccinated. This eagerness was attenuated by the lack of knowledge on where the vaccine could be gotten and the cost of vaccination. It is therefore pertinent that Federal and State Ministries of Health design and deploy massive awareness programs for the HPV vaccine, subsidize the cost of the vaccination and scale up available sites where these vaccinations could be accessed and accelerate the processes for its inclusion in routine immunization schedule.


We acknowledge the following research assistants who were involved in the data collection: Eze CW, Alaku CO, Ufondu IH, and Osuji-Ilomuanya U.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

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  [Table 1], [Table 2], [Table 3], [Table 4]

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