Knowledge and attitude toward human papillomavirus vaccination and associated factors among adolescent school girls in Ambo town, Ethiopia, 2021: A multicenter cross‐sectional study

Abstract Background and Aims The human papillomavirus (HPV) vaccination has shown considerable promise in lowering the incidence of cervical cancer. However, there are few studies done on knowledge and attitude toward the HPV vaccine, especially in the local setting. Therefore, this study aimed to assess knowledge and attitudes regarding HPV vaccination and related factors among adolescent girls in Ambo town, Ethiopia, in 2021. Methods A cross‐sectional study was conducted from May 1 to May 30, 2021, at selected schools in Ambo town among 422 adolescent girls. A structured self‐administered questionnaire was used to collect the data. The collected data were coded, and entered into Epi‐Info 7.2.2.6 and exported to STATA 16 for analysis. Descriptive statistics were used to compute summary statistics and proportions. Bivariate and multivariate logistic regression analyses were carried out. The adjusted odds ratio (AOR) along with a 95% confidence interval (CI) was computed to ascertain the association. Results Current study revealed that 24.9% (95% CI: 20.8–29.0) and 55.6% (95% CI: 50.5–60.4) of respondents had good knowledge and favorable attitude, respectively. The factors like being secondary school students [AOR = 2.01, 95% CI; (1.24, 3.27)], having health workers as a source of information [AOR = 2.13, 95% CI; (1.30, 3.47)], and respondents who have heard about the HPV vaccine at school [AOR = 1.66, 95% CI; (1.02, 2.71)] were significantly associated with respondent's knowledge of HPV vaccine. Moreover, the perceived severity of the diseases [AOR = 2.89, 95% CI; (1.61, 5.21)], and the perceived benefit of the vaccine [AOR = 4.26, 95% CI; (2.43, 7.48)] were factors significantly associated with an attitude of the respondents about the HPV vaccine. Conclusion There was low knowledge and unfavorable attitude toward HPV vaccination among the school adolescents in the study area. Several seemingly major deterrents of knowledge and attitude toward the HPV vaccination were identified. Therefore, all parties involved should collaborate to improve female students' knowledge and attitudes toward Human Papilloma Virus vaccination.


| BACKGROUND
The human papillomaviruses (HPVs) are a large family of tiny, nonenveloped, double-stranded, circular RNA viruses that are extremely prevalent. As sexual contact begins, both men and women are quickly exposed to it. 1,2 The nononcogenic HPV types 6 and 11 are thought to be the main sources of 90% of genital warts, whereas strains 16 and 18 of HPV are the most common causes of cervical cancer (CC). 3 Each year, there are around 560,000 new cases of CC and about 275,000 deaths, with more than 80% taking place in underdeveloped nations. 3,4 A woman dies from CC every 2 min. This is the worst and a fourth leading cause of death, continues to affect approximately 570,000 women with around 311,000 deaths worldwide. In East Africa, it is estimated that CC affects 42.7 cases per 100,000 women and causes the death of 35 per 100,000 women. 5 CC is the second most common cancer among women in Ethiopia with an estimated annual death toll of 4884 and 7095 women are diagnosed with it. 6 More than 85% of those affected by HPV are young, uneducated women living in the world's poorest countries. Moreover, many of them were also mothers of young children whose survival was later cut short by the untimely death of their mothers. 5 The HPV vaccine is a prophylactic vaccine developed to prevent the most common high-risk strains and low-risk infections of HPV. 7 The bivalent HPV vaccine was introduced in Ethiopia on December 3, 2018 for 14-year-old girls. 8 To reach all 14-year-old females, the vaccine is presently predominantly administered through a schoolbased strategy. 9 However, obstacles to a successful HPV vaccination program in Ethiopia included social influence, a lack of understanding about CC and screening, and a lack of health education regarding the HPV vaccine. 10 A lack of understanding about the HPV vaccine was one cause of morbidity and mortality associated with the HPV. According to certain research, the majority of adolescents are unaware of the HPV vaccine, which is a significant obstacle to vaccination. 11,12 Most teens have a misunderstanding about the HPV vaccine, making it difficult to accept the vaccination. 12,13 Moreover, the successful implementation of a vaccination program is hampered by various key demographic factors like, age, educational level, occupation, and residence. 14 On the other hand, the acceptability of the HPV vaccine was affected largely due to unfavorable attitudes and beliefs toward the vaccine. 15,16 It was also shown that the reason for not being vaccinated was a delay, as well as a refusal based on the belief that vaccines were unnecessary. 17 These negative attitudes (hesitations) are not limited to those who refused vaccination but also to those who encourage others to refuse vaccination. As a result, many healthcare professionals have reported increasing difficulties to develop trusting relationships with parents and adolescents. 18,19 Poor knowledge and unfavorable attitudes have an impact not only on adolescents but also on others. Due to a lack of understanding and negative attitudes, 87.3% of teenagers did not have their parents or family support to be immunized. 15 According to data from the Centers for Disease Control and Prevention (CDC), most parents are unwilling to vaccinate their children due to a lack of awareness about the vaccine. 20 Most parents often delay the decision to get the HPV vaccine because they think their child was at low risk for HPV infection. 15,20 Thus, the respondent's negative perceptions, unfavorable attitudes as well as poor knowledge about the HPV vaccine impacted the implementation of the vaccination negatively. 21 The HPV vaccine has only recently been introduced in Ethiopia, and there have been relatively few studies looking at knowledge, attitude toward the HPV vaccine, and associated factors among adolescents.
Understanding the level of knowledge and attitude of adolescents about the HPV vaccine and related issues may be crucial for the vaccination program to be effective and the implementation of a good and wellrespected primary preventive program for CC. Thus, this study aimed to assess HPV vaccine knowledge, attitude, and the associated factors among adolescent girls in Ambo town, Ethiopia.

| Study setting, period, and design
The study was conducted in the town of Ambo, West Shewa zone, Because no studies in this area had been found at the time of the study, the sample size was computed using the single population proportion formula, based on the assumption of a proportion (P) of 50% that yields a maximum sample size. Moreover, Zα/2 = 1.96, the margin of error (d) = 5%, and the α value 0.05 were used. Therefore, assuming 10% as the nonresponse rate, the final total sample size was 422 study participants. Eight primary schools and 3 high schools were chosen at random from among the 16 primary schools and 6 high schools in the town of Ambo. The sample size was distributed proportionally to each selected school. Finally, study participants were selected from each school by using a simple random sampling technique with a computer-generated random number method.

Adolescence
The age between 10 and 19 years was considered an adolescent girl. 22 Knowledge There were three subsections of knowledge-related questions, specifically related to CC, HPV infection, and HPV vaccine with a maximum possible score of 32. The knowledge of CC, knowledge of HPV Infection, and the knowledge of HPV vaccine have 12, 13, and 7 knowledge-related questions, respectively. The total score was calculated and those with mean and below mean scores were considered as having poor overall knowledge, while those with the above mean score were displayed as having good overall knowledge.
The same approach was used for knowledge of CC, knowledge of HPV infection, and overall knowledge. 19 Attitude A total of seven items with a 5-point Likert scale was developed to measure attitudes toward the HPV vaccine. It was awarded 5 points for "totally agree" and reduced to 1 point for "totally disagree." Then, attitude scores were calculated for each participant, ranging from 0 to 7. Finally, a composite attitude variable was generated from the score using the mean as the cut-off point when checking for the normality of the score. Therefore, participants with above-mean scores were classified as having "favorable attitudes," while those with mean and below-mean scores were classified as having "unfavorable attitudes." 23 Perception A total of 13 items were constructed for all sections of perception.
Perception-related questions included the susceptibility of the diseases, the severity of the diseases, benefits of the HPV vaccine, and the barriers to HPV vaccination. As a result, each category has three items unless barriers to HPV vaccination which has four items.
The available responses were noted on a Likert scale. Therefore, a score below the mean indicates a stronger belief in refusing vaccination and was labeled as "Poor Perception" while a score above the average was considered to be "Good Perception." 23

| Independent variables
Independent factors were sociodemographic parameters (age, educational status, occupation, and place of residence), perception (perceived susceptibility, perceived severity, perceived benefit, and perceived barriers), and HPV vaccine promotion.

| Dependent variables
Knowledge and attitude toward HPV vaccine.

| Data collection tool and procedure
The questionnaire was prepared in the English language that was translated into Afaan Oromo and then translated back into English to check its consistency. The data collection tool has been adapted through a review of different pieces of literatures 3 and similar previous studies. 9,11,16,24 An eight-part questionnaire was developed to assess sociodemographic characteristics, knowledge about CC, knowledge about HPV infection and vaccination, attitudes toward HPV vaccination, the presence of HPV vaccination advertisements, and source of information. A self-administered Afaan Oromo version questionnaire was used to collect the data. The data were collected by eight experienced bachelor's degrees in nursing. On top of that, eight teachers were selected to facilitate the data collection process and three master's degree holder senior midwives were supervised the data collection process.

| Data quality assurance
Data collectors and supervisors received 2 days of training on the objectives of the study, the relevance of the study, confidentiality, YOHANNES ET AL. | 3 of 10 respondent's rights, informed consent, and interview techniques before the actual data collection period. The questionnaire was pretested on 5% of the samples at Ginchi high school to ensure the accuracy of the responses, the clarity of the language, and the applicability of the tool. Cronbach's α was used to assess the tool's internal consistency and validity with the value of 0.84. This proved that the survey was credible and legitimate. 25 The principal investigator and supervisors carried out on-site checks and reviews of all completed questionnaires to ensure the completeness and consistency of collected data. The principal investigator doublechecked the entered data regularly to ensure that it was accurate.

| Data processing and analysis
After data collection, each questionnaire was checked for completeness and entered into Ep-info version 7.2.2.6. Then, the data were exported to STATA version 16 for cleaning, coding, and final analysis.
The data were checked for missed values and outliers. Descriptive analysis (like frequencies, tables, percentages, means, and standard deviation) was done to describe the required variable. There were no outliers and missing data. We confirmed that the assumptions of the analysis were met. The variables with a p value of less than 0.25 on bivariate logistic regression with crude odds ratio (COR) at 95% confidence interval (CI) were considered to be the candidates for the multivariable logistic regression model. This study used the variable selection process by the backward-stepwise model during the initial stage of developing the model. Multivariable logistic regression with adjusted odds ratio (AOR) at the 95% CI was used to identify the final associated factors. A significance level of 0.05 was taken as a cutoff value for all statistical significance tests. A two-tailed test with p < 0.05 at the 95% CI was statistically significant. Multicollinearity was checked between each variable using the variance inflation factor. Accordingly, two variables were removed from multivariable logistic analyses (VIF = 9.95 & 11.5). A Pearson goodness-of-fit test was employed to evaluate the model's suitability 26

| Sociodemographic characteristics of respondents
In the current study, a total of 414 (98%) respondents out of 422 respondents were participated. The reason of 2% nonresponse rate was because they gave incomplete data during the study. The mean age of the participants was 15 years with a standard deviation of ±2.

| Factors associated with knowledge of respondents about HPV vaccination
Multiple logistic regression analysis showed that the educational status of the respondent and the existence of the source of information were associated with knowledge of HPV vaccination. which is almost comparable with a study conducted in Lagos, Nigeria (44.2%). 30 In contrast to our findings, another study from a developed country (Italy) showed that there were lower rates of unfavorable attitudes toward HPV vaccination (20%). 24 The disparity could be explained by inequalities in socioeconomic class, educational level, and inadequate coverage of targeted educational programs (low access to information among low-income countries. 29,31 Beyond assessing the prevalence rate, the study also pointed out factors that were associated with adolescent's knowledge and attitude toward the HPV vaccine. In this study, it was discovered that adolescent girls' knowledge about the HPV vaccine increased by about two times more than that of their counterparts when they had access to sources of information from health professionals and at school. This finding is consistent with another similar study from the United States, in which adolescents use school and health personnel as their primary sources of knowledge about HPV vaccine. 32 This is because most schoolgirls perceive health workers and school staff to be more knowledgeable about the vaccine than any other career, which is why the information provided by schools and health experts is reliable to them. This study also found that one of the factors associated with the knowledge of HPV vaccination was an adolescent's level of education. Those girls from secondary school were more knowledgeable than those from primary school. The finding was consistent with a finding from a similar study conducted on Mozambican and Nepali adolescents. 33,34 The reason might be because the students in high school were more likely to learn and read about HPV and CC. As a result, the CC education that was included in the Grade 10 curriculum supports the students to have an awareness of HPV vaccination. 35 Also, the results of this study showed that adolescents who had heard about the HPV vaccine (who had been exposed to information) before immunization had a more favorable attitude toward it. The result of this study is in line with the study conducted in Italy. 24 This is explained by the fact that, having preinformation about the vaccine helps in recognizing the benefits of the vaccine which in turn helps to develop a positive outlook for a vaccine.
Another finding of this study indicated that adolescents who

ACKNOWLEDGMENTS
We would like to thank Ambo University, the College of Medicine and Health Sciences, Department of Midwifery and Public Health for providing us with the opportunity to conduct this study. We would like to thank the West Shewa zonal Health Office, study participants, data collectors, and supervisors for their cooperation.

CONFLICT OF INTEREST STATEMENT
The authors declare no conflict of interest.

DATA AVAILABILITY STATEMENT
The data sets used and/or analyzed during the current study are available from the corresponding author upon written request.

ETHICS STATEMENT
The ethical approval was obtained from the Institutional Review

TRANSPARENCY STATEMENT
The lead author Ephrem Yohannes affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.