Human Papillomavirus (HPV) vaccination practices and associated factors among female adolescent students in Eastern Zone of Tigray, Northern Ethiopia, 2024

Abstract

Background:

Human papillomavirus (HPV) continues to pose a significant threat to public health, serving as the primary cause of cervical cancer. To address this issue, a vaccine has been developed to decrease the incidence of cervical cancer. However, the practice and its associated factors with the uptake of the vaccine have not been well studied in this particular region. Consequently, this study aims to evaluate the practice of HPV vaccination and its associated factors among female adolescent students in the Eastern Zone of Tigray, North Ethiopia, 2024.

Methods:

A cross-sectional study design was conducted from September 2023 to January 2024 at primary schools of the Eastern Zone, Tigray, Ethiopia. Data related to HPV vaccination practice and its associated factors were collected from 634 female adolescent primary school students. The collected data were checked for completeness daily, coded, entered, and cleaned using Epinfo version 7.2.3 then exported and analyzed using SPSS version 24. Bivariate and multivariate logistic regression analyses were used to assess the association between dependent and independent variables. The corresponding variables with a p-value (p < 0.05) with a 95% confidence interval were considered statistically significant.

Result:

Among the 634 participants, 61.7% received the quadrivalent Gardasil HPV vaccine. Of these, 52.1% (330/634) demonstrated good knowledge, with an adjusted odds ratio (AOR) of 1.931 (95% confidence interval (CI), 1.364–2.735) and a p-value < 0.000. Moreover, participants who had a positive attitude toward HPV vaccination, with (AOR = 1.529, 95% CI = 1.049–2.230; p-value < 0.027) and participants who expressed their agreement for taking the HPV vaccine (AOR = 1.816, 95% CI = 1.046–3.152; p-value < 0.034) were factors associated with female adolescent students’ practice of the HPV vaccination.

Conclusion and recommendation:

The results indicated that the majority of study participants received one dose of the HPV vaccine. The study further reveals several factors associated with HPV vaccination among female adolescent students, including a positive attitude toward the vaccine and good knowledge about its benefits. Health authorities are recommended to promote the HPV vaccine through mass media in schools, religious institutions, and healthcare facilities to increase practice among adolescent females.

Back ground

Cervical cancer represents a significant global health challenge, particularly affecting women’s well-being worldwide, with escalating rates of morbidity and mortality. ¹ The burden of this disease is especially pronounced in developing regions, where healthcare access is often limited. In 2020, the global diagnosis of approximately 604,000 new cases of cervical cancer resulted in 342,000 deaths. ² Sub-Saharan Africa bears a considerable share of this burden, with an annual incidence of 35 new cases and 23 fatalities per 100,000 women. ³

In Ethiopia, cervical cancer ranks as the second most prevalent cancer among women, with approximately 4648 new cases diagnosed and 3235 annual fatalities. ² The primary causative agent of cervical cancer is human papillomavirus (HPV), the most prevalent sexually transmitted infection globally, infecting approximately 75% of sexually active individuals during their lifetime. ⁴ Notably, 70% of cervical malignancies are attributed to HPV strains 16 and 18. ⁵

However, cervical cancer is largely preventable through HPV infection prevention strategies, chiefly through highly effective and cost-efficient HPV vaccination. ⁶ Vaccines such as Quadrivalent Gardasil, Cervix, and Gardasil 9, licensed by the Food and Drug Administration (FDA) in 2006, 2009, and 2014, respectively, are instrumental in preventing HPV infection (FDA, 2006; FDA, 2009; FDA, 2014). Recognizing the significance of HPV vaccination, the WHO recommends vaccinating girls aged 9–14 as a cost-effective public health intervention against cervical cancer.^7–9 By 2020, over half of the World Health Organization (WHO) member countries have initiated HPV vaccination programs, aiming to achieve a 90% elimination rate of HPV-related diseases by 2030. ¹⁰ Studies have shown significant reductions in HPV16 and 18 infections among vaccinated females aged 9 to 14 years, indicating its effectiveness in preventing cervical cancer cases. ¹¹

Despite global efforts deemed in place, there remains a disparity in HPV vaccine coverage, with industrialized nations exhibiting higher rates than poorer countries. ² In Ethiopia, the HPV vaccination program commenced on December 6, 2018, with over two million girls vaccinated nationwide under two schedules at the age of 14. ¹²

Studies in Gambela and Bahir Dar City show that the willingness to receive the HPV vaccine ranges from 50.6% to 56%, with factors such as knowledge, attitude, and family approval influencing acceptance. Challenges such as low knowledge and uptake rates, especially in rural areas, highlight the need for increased public health education and community mobilization efforts.

Given the importance of HPV vaccination in preventing cervical cancer, especially among adolescent girls who have not initiated sexual activity, understanding vaccination practices and associated factors is crucial. This study aimed to assess the level of HPV vaccine uptake and explore contributing factors among female adolescent students in the Eastern Zone of Tigray, North Ethiopia, 2024.

Methods and materials

Study area

The study was conducted in the Eastern Zone of Tigray, Ethiopia, located approximately 870 km from Addis Ababa, the capital city of Ethiopia. According to data from the zone health office for the 2017–2018 period, the total population of the zone was 774,155, with approximately 49% being males and the remaining females.

The study area includes seven urban districts and eleven rural districts. Within the 11 rural districts, there are 264 government primary schools, with no private primary schools available. By contrast, the 7 urban districts boast 24 government primary schools and 12 private primary schools, resulting in a total of 300 government and private schools in the study area.

For the academic year 2023–2024, a total of 38,093 female students were enrolled in these primary schools. These figures regarding the number of primary schools, students, and their gender offer insights into the current state of education within the study area. ¹³

Study period

The study was conducted from January 2023 to January 2024.

Study design

An institutional-based cross-sectional study design was conducted.

Population

Source population

All female students enrolled at primary schools of the Eastern Zone of Tigray for the academic year of 2023–2024.

Study population

All female students in selected primary schools of the Eastern Zone of Tigray for the 2023–2024 academic year were our study population.

Eligibility criteria

Inclusion criteria

Those female adolescent students aged 9 and above.

Exclusion criteria

Participants who are younger than 9 years.

Students who have not resided in the community for at least 6 months.

Sample size determination and sampling procedure

Sample size determination

The sample size was computed using a single population proportion formula with the estimated population parameters of the prevalence of the study done in Arbaminch 50.4%, ⁶ a level of confidence of 95% and a margin of error of 5% to get a maximum sample size of 634 after adding 10% of non-response rate.

$$\begin{array}{l}n=\frac{{(Z\alpha /2)}^2\left(P\right)(1-P)}{d^2}\ast \mathrm{de}=\\ n=\frac{(1.96)(1.96)(0.717)(0.283)}{(0.05)(0.05)}\ast 1.5=\end{array}$$

Sampling technique and procedure

The Eastern Zone of Tigray Region was deliberately chosen for this study. This zone comprises 18 districts, which are further categorized into rural and urban areas. Among these, 11 districts are rural and 7 are urban. The primary schools in these areas fall into two classifications: public and private. Within the 11 rural districts, there are 264 public primary schools and no private primary schools. Conversely, the 7 urban districts have 24 public primary schools and 12 private primary schools. In total, there are 300 primary schools, encompassing both public and private (Supplemental Material).

Multi-stage sampling technique was used in this study. To ensure representativeness, a minimum ratio of 30% was employed. Four private primary schools were randomly selected from the 12 available, and 79 public primary schools were chosen from the 264 rural districts, along with 24 public primary schools from the urban districts using simple random sampling. The allocated sample size was then proportionally distributed to each school, and study units were randomly selected from each school’s sample frame.

The population proportion sampling to size allocation was utilized to distribute the selected participants proportionally across grades 5, 6, 7, and 8 in both private and public schools. Finally, study participants were randomly chosen from their respective schools, grades, and sections. Data collection was conducted by teachers from the selected schools under the supervision of data collection facilitators and supervisors, who were appointed by Adigrat University lecturers. Participants were gathered at a designated location within their school premises, under the supervision of facilitators and supervisors, to fill out the questionnaire for data collection (Figure 1).

Figure 1.

Schematic presentation of the sampling procedure, Eastern Zone, Tigray, North Ethiopia, 2024.

Operational definitions

Good knowledge of HPV vaccination

Those who answered 50% or more of the knowledge assessment questions. ¹⁴

Poor knowledge of HPV vaccination

Those who answered below the mean (50%) of the knowledge assessment questions. ¹⁴

Positive attitude on HPV vaccination

Those respondents who score median or above for HPV vaccination attitude, assessed by questions. ¹⁵

Negative attitude toward HPV vaccination

Those respondents who score below the median score for HPV vaccination attitude, assessed by questions. ¹⁵

HPV vaccination practiced

A student who has ever received an HPV vaccination at least once has practiced. ¹⁶

HPV vaccination not practiced

A student who has never received an HPV vaccination at least once has not practiced. ¹⁶

HPV vaccine

Vaccine against the most common HPV genotypes associated with cervical cancers, which are HPV16 and HPV18. ¹⁷

Data collection tools and procedures

To gather comprehensive data on the practice and associated factors toward the HPV vaccine in primary school students, a survey was developed using multiple reliable sources. The survey was carefully created by selecting, modifying, and adapting relevant and standard evaluation tools from previously published research on similar topics of study.^2,6,7,9,13 This ensured that the survey content was both valid and reliable. The questionnaire is composed of variables related to sociodemographics, sources of information, and practice and its associated factors. The sociodemographic variables include students’ age, gender, and educational level, while the sources of information variables measure the different sources from which the students acquired their knowledge on the HPV vaccine. The questionnaire was initially prepared in English, which is the primary language of instruction in the study area. To ensure that all participants could easily understand the questions, the questionnaire was translated into the Tigrigna language, which is the local language spoken by the majority of the population in the study area. The translation process was carefully done to maintain the questionnaire’s original intent and meaning. The final version of the questionnaire was deployed into the Kobo tool database, which is a reliable and efficient platform for data collection. This ensured that data collection was accurate and efficient. The study team reviewed the questionnaire and pilot-tested it to ensure that it was clear and understandable to the participants. The survey was conducted safely and ethically with strict adherence to confidentiality and informed consent procedures.

Data quality control

Nine data collectors and three supervisors were trained in data collection equipment and sampling techniques. Before data collection, a pre-test was administered in one primary school to 5% of the sample size. The pretest results were altered before being repeated for data collection. Supervisors helped data collectors choose research participants from each school, and they offered on-site supervision throughout data collection. Supervisors and investigators confirmed the completeness, accuracy, consistency, and clarity of all completed questionnaires by data collectors.

Data processing and analysis

Data were entered into Epi Info Version 7 and exported for analysis to SPSS Version 24. A descriptive analysis was performed, and measures of central tendency (mean) were determined. Logistic regression was used to determine the relationship between the dependent and independent variables. Independent variables with a p-value < 0.25 in bivariable analysis were included in a multiple logistic regression model. Independent variables with a p-value < 0.05 in the multiple logistic regression models were considered statistically significant for HPV vaccination acceptance. The results were reported as odds ratios (ORs) with 95% confidence intervals. The link between a dependent variable and independent variables was quantified using an odds ratio with a 95% confidence interval (CI). The Hosmer–Lemeshow test was used to check the model’s fitness.

Ethical consideration

The study was approved by the College of Medicine and Health Sciences Research Ethical Review Committee of Adigrat University, Ethiopia (Consent Ref Number AGU/CMHS/049/2023 approval dated 15/07/2023. An official letter was obtained from the Tigray Regional Health Bureau and each district education office (Consent Ref Number AGU/CMHS/RCSH/19/2023 approval dated 25/07/2023. Written informed consent was sought from each study participant, and before the interview maintained throughout the study. All participants were given code numbers to keep their identity confidential.

Results

Sociodemographic characteristics of study participants

A total of 634 female adolescent students participated in this study, with a response rate of 100%. Of these, 310 (48.9%) respondents were aged between 11 and 13 years, and the mean age was 13.5 years with a standard deviation of ±1.27. The majority of the respondents, 318 (50.2%), were grade 7 and 8 students, and 555 (87.5%) of the respondents were from rural districts. Approximately half, 331 (52.2%), of the respondents reported that their mothers were illiterate (Table 1).

Table 1.

Sociodemographic characteristics of study participants at the primary school of Eastern Zone, Tigray, Ethiopia, 2024 (N = 634).

Variables	Category	Frequency	Percent
Age	11–13 years	310	48.9
	14–15 years	125	19.7
	>15 years	199	31.4
Grade level	Grades 5 and 6	316	49.8
	Grades 7 and 8	318	50.2
Type of school	Public	604	95.3
	Private	30	4.7
Residence	Rural	555	87.5
	Urban	79	12.5
Marital status of mother and father	Married	539	85.0
	Single	36	15
Mother’s educational status	Unable to read and write	331	52.2
	Primary education	196	30.9
	Secondary education	83	13.1
	College and above	24	3.8
Father’s educational status	Unable to read and write	279	44.0
	Primary education	145	22.9
	Secondary education	174	27.4
	College and above	36	5.7
Father’s occupation	Farmer	522	82.3
	On his own private Work	40	6.3
	Government employee	72	11.3
Mother’s occupation	Farmer	524	82.6
	House wife	45	7.1
	Private work	29	4.6
	Government employee	36	5.6
With whom are you currently living?	With both parents	471	74.3
	With my mother	103	2.8
	With my father	18	16.2
	With my friends	2	0.3
	With relatives	38	6.0
	Living alone	2	3
Family size	>3	49	7.7
	4–6	426	67.1
	Above 7	159	25.1
Monthly income	<1000 ETB	557	87.9
	1001–2500 ETB	24	3.8
	2501–3500 ETB	20	3.2
	>3501 ETB	33	5.2

Primary sources of information about HPV vaccine at Eastern Zone, Tigray, Ethiopia, 2024 (N = 634)

Regarding the sources of information, 23.3% of the participants identified health professionals as their primary source, while 21% relied on mass media. In addition, 11.5% of the participants mentioned school as their primary source of information (Figure 2).

Figure 2.

Source of information regarding human papillomavirus vaccine among female adolescent students at Eastern Zone, Tigray, Ethiopia from September 2023 to January 2024 (N = 634).

Knowledge about HPV vaccine among female adolescent students at Eastern Zone, Tigray, Ethiopia, 2024 (N = 634)

The study revealed that 330 (52.1%) of the 634 participants had good knowledge about the HPV vaccine. Furthermore, 280 (44.2%) participants were aware that the HPV vaccine is currently available for free to female adolescents. In addition, 300 (47.3%) respondents believed that female adolescents should receive the HPV vaccine before initiating sexual activity. Finally, 337 (53.2%) participants believed that the HPV vaccine is effective in preventing cervical cancer (Table 2).

Table 2.

Knowledge toward HPV vaccination of female adolescent students at the primary school of Eastern Zone, Tigray, Ethiopia, 2024 (N = 634).

Variables	Categories	Frequency	Percent
Have you ever heard about the HPV vaccine before?	Yes	416	65.6
	No	218	34.4
If you say yes to Q201, from where have you heard about the HPV vaccine?	Health facilities	148	23.3
	School	73	11.5
	Mass media	133	21.0
	My relatives	55	8.6
Currently HPV vaccine is only given to Ethiopian girls	Yes	173	27.3
	No	461	72.7
HPV vaccination is currently offered freely to female adolescents	Yes	280	44.2
	No	354	55.8
When do female adolescents start the HPV vaccine	In the first year of life	270	42.6
	Before starting sexual intercourse	300	47.3
	After sexual intercourse	64	10.3
At what age can female adolescents start HPV vaccination	5–8 years	29	4.6
	9–14 years	376	59.3
	15–18 years	216	34.1
	>18 years	13	2.1
HPV vaccine is delivered in a series of two injections over a 6-month schedule (0 and 6 months)	Yes	325	51.3
	No	309	48.7
HPV vaccine can prevent the development of genital warts and cervical cancer	Yes	348	54.9
	No	286	45.1
HPV vaccine can protect against all viruses that cause cervical cancer	Yes	218	34.4
	No	416	65.6
HPV vaccine can protect against all STIs	Yes	230	36.3
	No	404	63.7
HPV vaccine is safe and has no major side effects	Yes	202	31.9
	No	432	68.1
HPV vaccine is effective in the prevention of cervical cancer	Yes	337	53.2
	No	297	46.8
HPV vaccine is effective if it is delivered to one person only	Yes	266	42.0
	No	368	58.0
Those females who took the HPV vaccine should perform pap smear	Yes	291	45.9
	No	343	54.1
Knowledge level	Poor	304	47.9, 95% CI (17–32)
	Good	330	52.1, 95% CI (19–34)

HPV, human papillomavirus.

Attitude toward the HPV vaccine

The study involved 634 participants, out of which 265 (41.8%) agreed on the efficacy of the HPV vaccine in preventing cervical cancer. Conversely, 270 (42.6%) of the respondents remained undecided about the vaccine’s effectiveness, while 99 (15.6%) individuals completely disagreed. With regard to the perceptions of cervical cancer severity, 300 (47.3%) respondents reported severe disease, while 80 (12.6%) disagreed with this perspective. In terms of the safety profile of the HPV vaccine, 226 (35.6%) believed there were no significant side effects. while 405 (63.7%) individuals held a neutral view, and 284 (44.8%) remained undecided (Table 3).

Table 3.

Level of attitude on HPV vaccine among female adolescent students at Eastern Zone, Tigray, Ethiopia, 2024 (N = 634).

Variable	Category	Frequency	Percent
HPV infections can cause cervical cancer	Agree	276	43.5
	Neutral	254	40.1
	Disagree	104	16.4
Is cervical cancer a deadly disease	Agree	300	47.3
	Neutral	254	40.1
	Disagree	80	12.6
Believe that the HPV vaccine can prevent cervical cancer	Agree	265	41.8
	Neutral	270	42.6
	Disagree	99	15.6
Believe that the HPV vaccine is safe and effective	Agree	226	35.6
	Neutral	405	63.9
	Disagree	3	0.5
Do you think being vaccinated for HPV reduces the risk of HPV infection	Agree	349	55.0
	Neutral	284	44.8
	Disagree	1	0.2
I will take the vaccine because I feel at risk of getting the HPV infection	Agree	419	66.1
	Neutral	147	23.2
	Disagree	68	10.7
HPV vaccine is possible to take during pregnancy	Agree	170	26.8
	Neutral	305	48.1
	Disagree	159	25.1
Even though you took the HPV vaccine, you are at risk of developing cervical cancer	Agree	174	27.4
	Neutral	291	45.9
	Disagree	169	26.7
HPV can be transmitted from mother to child during delivery	Agree	293	46.2
	Neutral	257	40.5
	Disagree	84	13.2
Believe HPV infection is a serious disease	Agree	357	56.3
	Neutral	211	33.3
	Disagree	66	10.4
Believe that if the HPV vaccine is effective against HPV, I can take the vaccine	Agree	262	41.3
	Neutral	272	42.9
	Disagree	100	15.8
During sexual intercourse, a condom can prevent HPV infection	Agree	282	44.5
	Neutral	255	40.2
	Disagree	97	15.3
Level of attitude	Negative	324	51.1, 95% CI (19–34)
	Positive	310	48.9, 95% CI (18–32)

HPV, human papillomavirus.

Status attitude among female adolescents about the HPV vaccine

In summary, the study assessed the attitudes of 634 participants toward HPV vaccination, with 324 (48.9%) exhibiting a positive attitude and 310 (51.1%) expressing a negative attitude.

HPV vaccination practice among female adolescent students

Out of these participants, 391 (61.7%) received at least one dose of the HPV. The reasons for failure to take the vaccine were 129 (20.3%) lacked prior information about the vaccine, 17 (2.7%) reported fear of side effects, and 82 (12.5%) felt less confident about the benefits of the vaccine.

Factors associated with the practice of the HPV vaccination

Bivariate and multivariate logistic regression analyses were performed to assess the association between dependent and independent variables. In the bivariate analysis, type of school, residence, mother’s educational status, father’s educational status, and adolescent girls who should take HPV, knowledge, and attitude were found to be associated with Human papillomavirus vaccination practice and were transported to multivariate analysis.

In the multivariate analysis, adolescent girls who agreed to receive HPV vaccination (AOR = 1.816, 95% CI: 1.046–3.152, p = 0.034), those who had good knowledge (AOR = 1.931, 95% CI: 1.364–2.735, p = 0.000), and adolescent girls who had a positive attitude (AOR = 1.529, 95% CI: 1.049–2.230, p = 0.027) were significantly associated with practice HPV vaccination (Table 4).

Table 4.

Bivariate and multivariate logistic regression factors associated with the practice of HPV vaccine among female adolescent students at the primary school of Eastern Zone, Tigray Region, North Ethiopia, 2024 (n = 634).

Variables	Category	Practice		COR (95% CI)	p Value	AOR (95% CI)	p Value
		Practiced	Not Practiced
School type	Government	366 (60.6%)	238 (39.4%)	1		1
	Private	25 (83.3%)	5 (16.7%)	3.251 (1.228–9.611)	0.018	0.381 (0.093–1.560)	0.180
Residence	Rural	327 (58.9%)	228 (41.1%)	1
	Urban	64 (81.0%)	15 (19.0%)	2.975 (1.654–5.351)	0.000	1.005 (0.302–3.340)	0.994
Mother’s educational status	No education	188 (56.8%)	143 (43.2%)	1		1
	Primary Education	125 (63.8%)	71 (36.2%)	1.339 (0.931–1.926)	0.115	6.348 (0.604–66.740)	0.124
	Secondary Education	59 (71.1%)	24 (28.9%)	1.870 (1.109–3.151)	0.019	6.766 (0.662–69.121)	0.107
	Above Secondary	19 (79.2%)	5 (20.8%)	2.890 (1.054–7.927)	0.039	6.592 (0.645–67.353)	0.112
Father’s educational status	No education	156 (55.9%)	123 (44.1%)	1		1
	Primary Education	90 (62.1%	55 (37.9%)	1.290 (0.856–1.945)	0.224	0.135 (0.011–1.721)	0.123
	Secondary Education	113 (64.9%)	61 (35.1%)	1.461 (0.988–2.159)	0.058	0.147 (0.012–1.801)	0.134
	Above Secondary	32 (88.9%)	4 (11.1%)	6.308 (2.172–18.315)	0.001	0.168 (0.014–2.021)	0.160
I will take the vaccine because I feel at risk of getting the HPV infection	Agree	284 (67.8%)	135 (32.2%)	2.511 (1.494–4.221)	0.001	1.816 (1.046–3.152)	0.034**
	Neutral	76 (51.7%)	71 (48.3%)	1.278 (0.718–2.274)	0.405	1.347 (0.742–2.443)	0.328
	Disagree	31 (45.6%)	37 (54.4%)	1		1
Knowledge	Good	157 (51.6%)	147 (48.4%)	2.282 (1.645–3.166)	0.000	1.931 (1.364–2.735)	0.000**
	Poor	234 (70.9%)	96 (29.1%)	1		1
Attitude	Positive	174 (53.7%)	150 (46.3%)	2.011 (1.451–2.789)	0.000	1.529 (1.049–2.230)	0.027**
	Negative	217 (70.0%)	93 (30.0%)	1		1

^**p < 0.05 (significantly associated).

1, Reference category; AOR, adjusted odds ratio; CI, confidence interval; HPV, human papillomavirus.

Discussion

Knowledge and attitudes toward prophylactic HPV vaccination were assessed using a questionnaire among 634 primary school adolescent female students in the Eastern Zone of Tigray.

In the current study, the overall practices of the HPV vaccine among adolescent girls were found to be 61.7%. This finding was lower compared with a similar study conducted in Ethiopia 66.5%, ¹⁶ Mali 100%, ¹⁸ Mozambique 91%, ¹⁹ and China 66.9%. ¹⁹ The possible explanation for this difference could be due to the increased level of awareness in Mali and Mozambique, and variation in methodology in China, the difference in the population studied, and the level of awareness in the HPV transmission method. In addition, the impact of the genocidal war on Tigray, which led to the blockage of schools and a lack of vaccination, may also have influenced the results. However, the present study was higher compared to the results found in the Netherlands 39%, ²⁰ Lira district, Uganda 17.61%. ⁹ This could be a result of different sample sizes, study populations, and differences in strategies for the healthcare delivery system. Moreover, differences in the operational definition of vaccination completion, such as the definition of three doses in Uganda versus the current study’s definition of receiving at least one dose, may contribute to the observed disparities. ⁹

Furthermore, the current study identified several factors that were significantly associated with the uptake of the HPV vaccine. Specifically, adolescent girls who had positive beliefs and attitudes toward HPV vaccination and who had good knowledge were more likely to receive the vaccine.

Participants who indicated their willingness to receive vaccination against HPV were 1.816 times more likely to do so compared to those who were neutral or disagreed. This finding is similar to a study conducted in Benin City, Nigeria, ²¹ and Uganda. ⁹ It is possible that the majority of motivating and initiative factors in adolescents’ practices are generated by their positive attitude. Furthermore, it has been suggested that effective delivery strategies and consistent messaging on the benefits of the HPV vaccine may be necessary. ²²

This study found that 52.1% of female primary school students in the study area had knowledge about HPV vaccination. Participants who had good knowledge of the vaccine and its benefits were 93% more likely to receive the HPV vaccine compared to those who had poor knowledge. This finding was consistent with similar studies conducted in Ethiopia, such as in Mettu town, southwest, ²³ North Shoa, ¹⁶ Debre Tabor, ¹⁴ Arba Minch, ⁷ and Bahir Dar, ⁴ Harar, Ethiopia, ²⁴ in Brazil 51.79%, ²⁵ Italy 56.3%, ²⁶ and Malaysia 50.8%. ²²

This can be explained by the fact that female adolescents with good knowledge were adequately informed of the advantages of receiving the HPV vaccine. However, this study was relatively higher than with the findings reported from Debre Markos, Ethiopia 47.6%, ²⁷ Indonesia 44.4%, ²⁸ India 44%, ²⁹ although this finding is slightly lower than the study done in Italy 56.3%. ²⁶ This variation might be due to differences in the method of study, differences in sample size, study population, level of knowledge about human papillomavirus infection, and access to vaccination.

In this study, female adolescents who had a positive attitude toward vaccination were 52% more likely to receive HPV vaccination than female adolescents who had a negative attitude toward vaccination. This study was in agreement with previous studies conducted in Arba Minch in Ethiopia, ²⁴ Ambo in Ethiopia, ⁶ Uganda, ⁹ Jinan of China, ³⁰ and Melaka Malaysia. ³¹ The results of this study suggest that the decision to receive the HPV vaccine may be influenced by an individual’s perception of the seriousness of HPV infection and the potential benefits of the vaccine in protecting against the infection and maintaining good health. This finding is supported by a study conducted in the Ari District of South Omo Zone, Ethiopia, which found that adolescents with a positive attitude toward reproductive health were five times more likely to use reproductive health services. This might be the result of their internal perceptions of the seriousness of HPV infection and the potential benefits of the vaccine in terms of protecting them from the infection and maintaining their health, which could have inspired them to receive vaccination. This finding is also supported by the study conducted in the Ari District, South Omo Zone, Ethiopia, where adolescents with a positive attitude toward reproductive health were five times more likely to use reproductive health services. ³² In addition, studies conducted in Brazil revealed that having positive attitudes toward HPV vaccination reinforces the appropriate practice of vaccination. ³³ This can be explained by the fact that motivating factors of adolescents’ practice are generated from their positive attitude, which can be concluded as the impact of an attitude on behavior. As evidenced by research conducted in Ethiopia’s Ambo town ³⁴ and Gondar town, ¹⁴ adolescents who have previously learned about the HPV vaccine have a higher tendency to have a good attitude about it (62.8%), according to the current study. This may be because students who have prior knowledge of the vaccination are more likely to be able to distinguish and identify various vaccine-related ideologies.

Generally, being knowledgeable about the HPV vaccine and a positive attitude toward the HPV vaccine were significantly associated factors for the practice of HPV vaccination by adolescent female students in the study area. The findings suggest that a significant proportion of individuals have poor knowledge and a negative attitude toward HPV vaccination, which highlights the need for targeted interventions to improve vaccine practice.

Limitations

It is important to note that the study’s findings were based on self-reported responses from participants, which could lead to information bias. Hence, the study was mainly focused on behavior-based predictors with a qualitative approach to an individual, it lacks qualitative aspects to deal with in-depth community and health system-related factors. In addition, the study’s findings are only applicable to the same population of the same age group.

Conclusion and recommendation

Based on the study’s results, the practice of the HPV vaccine among adolescent girls in primary school in the Eastern Zone of Tigray was found to be 61.7%. Having good knowledge about the HPV vaccine and holding a positive attitude toward it were found to be significantly associated factors with the practice of HPV vaccination among adolescent girls in the study area. Therefore, we recommend that the Eastern Zone’s health offices conduct mass HPV vaccinations and community mobilization to increase the knowledge and attitudes of primary school adolescent girls toward the practice of HPV vaccination. All governmental and non-governmental stakeholders should collaborate to improve adolescent girls’ knowledge and attitudes toward HPV vaccination.