Implementation of an HPV vaccination program in Eldoret, Kenya: results from a qualitative assessment by key stakeholders

Background: Cervical cancer strikes hard in low-resource regions yet primary prevention is still rare. Pilot projects have however showed that Human Papillomavirus (HPV) vaccination programs can attain high uptake. Nevertheless, a study accompanying a vaccination demonstration project in Eldoret, Kenya, revealed less encouraging outcomes: uptake during an initial phase targeting ten schools (i.e., 4000 eligible girls), was low and more schools had to be included to reach the proposed number of 3000 vaccinated girls. The previously conducted study also revealed that many mothers had not received promotional information which had to reach them through schools: teachers were sensitized by health staff and asked to invite students and parents for HPV vaccination in the referral hospital. In this qualitative study, we investigate factors that hampered promotion and vaccine uptake. Methods: Focus group discussions (FGD) with teachers (4) and fathers (3) were organized to assess awareness and attitudes towards the vaccination program, cervical cancer and the HPV vaccine, as well as a FGD with the vaccinators (1) to discuss the course of the program and potential improvements. Discussions were recorded, transcribed, translated, and analyzed using thematic analysis In addition, a meeting with the program coordinator was set up to reflect upon the program and the results of the FGD, and to formulate recommendations for future programs. Results: Cervical cancer was poorly understood by fathers and teachers and mainly linked with nonconforming sexual behavior and modern lifestyle. Few had heard about the vaccination opportunity: feeling uncomfortable to discuss cervical cancer and not considering it as important had hampered information flow. Teachers requested more support from health staff to address unexpected questions from parents. Non-uptake was also the result of distrust towards new vaccines. Schools entering the program in the second phase reacted faster: they were better organized, e.g., in terms of transport, while the community was already more familiarized with the vaccine. Conclusions: Close collaboration between teachers and health staff is crucial to obtain high HPV vaccine uptake among schoolgirls. Promotional messages should, besides providing correct information, tackle misbeliefs, address stigma and stress the priority to vaccinate all, regardless of lifestyle. Monitoring activities and continuous communication could allow for detection of rumors and unequal uptake in the community

Uptake of the human papillomavirus vaccine in Kenya : testing the health belief model through pathway modeling on cohort data

Background: Many studies investigate HPV vaccine acceptability, applying health behavior theories to identify determinants; few include real uptake, the final variable of interest. This study investigated the utility of the Health Belief Model (HBM) in predicting HPV vaccine uptake in Kenya, focusing on the importance of promotion, probing willingness to vaccinate as precursor of uptake and exploring the added value of personal characteristics. Methods: Longitudinal data were collected before and after a pilot HPV vaccination program in Eldoret among mothers of eligible girls (N = 255). Through pathway modeling, associations between vaccine uptake and the HBM constructs, willingness to vaccinate and adequate promotion were examined. Adequate promotion was defined as a personal evaluation of promotional information received. Finally, baseline cervical cancer awareness and socio-demographic variables were added to the model verifying their direct, mediating or moderating effects on the predictive value of the HBM. Results: Perceiving yourself as adequately informed at follow-up was the strongest determinant of vaccine uptake. HBM constructs (susceptibility, self-efficacy and foreseeing father's refusal as barrier) only influenced willingness to vaccinate, which was not correlated with vaccination. Baseline awareness of cervical cancer predicted uptake. Conclusions: The association between adequate promotion and vaccination reveals the importance of triggers beyond personal control. Adoption of new health behaviors might be more determined by organizational variables, such as promotion, than by prior personal beliefs. Assessing users' and non-users' perspectives during and after implementing a vaccination program can help identifying stronger determinants of vaccination behavior

Introduction of HPV vaccination in Kenya

HPV vaccination prevents cervical cancer, the fourth most common cancer among women worldwide. Measured HPV vaccine acceptability is often high but does it also lead to high uptake? Methodology: A cohort was set up assessing HPV vaccine acceptability and other health behav- iour constructs before, and vaccine uptake after an HPV vaccination programme in Eldoret, Kenya. Focus groups shed light on the motivation for vaccine uptake or refusal. Results: Acceptability was high but was no strong predictor of uptake, and neither were the constructs of the Health Belief Model. Lack of information and fear of side effects were major barriers. Feeling uncomfortable to discuss cervical cancer hampered open communication. Discussion: Distrust towards new vaccines and the health system blocked translation from willingness-to-vaccinate to actual uptake, as did organizational factors such as poor promotion. Conclusion: Future research should include broader concepts such as vaccine hesitancy and factors beyond personal control in order to predict vaccine uptake. Key words: HPV vaccination, acceptability, uptake, longitudinal study, Keny

Analyzing the impact of zebra mussels (Dreissena polymorpha) on water nutrient levels.

General EcologyWe studied changing water nutrient levels in tanks filled with different densities of zebra mussels. This study took place on University of Michigan Biological Station Property in the northern Lower Peninsula of Michigan . We placed zebra mussels from Douglas Lake into five tanks at the Alfred H. Stockard Lakeside Laboratory. We then took water samples every hour for 8 hours so that we could analyze changes in nutrient levels over time. Through chemical analysis, we were able to examine the concentrations of 14 nutrients; however, only 4 nutrients (nitrite, nitrate, ammonium, and calcium) had changed significantly. The results showed that the amount of ammonium increased over time, calcium and nitrate decreased with increasing density , and ammonium increased with increasing density. These shifts in nutrient levels indicated that zebra mussel infestation can have a huge impact on aquatic ecosystems.http://deepblue.lib.umich.edu/bitstream/2027.42/136116/1/Vermandere_Kelly_2016.pd

Uptake of three doses of HPV vaccine by primary school girls in Eldoret, Kenya : a prospective cohort study in a malaria endemic setting

Background: All women are potentially at risk of developing cervical cancer at some point in their life, yet it is avoidable cause of death among women in Sub- Saharan Africa with a world incidence of 530,000 every year. It is the 4th commonest cancer affecting women worldwide with over 260,000 deaths reported in 2012. Low resource settings account for over 75% of the global cervical cancer burden. Uptake of HPV vaccination is limited in the developing world. WHO recommended that 2 doses of HPV vaccine could be given to young girls, based on studies in developed countries. However in Africa high rates of infections like malaria and worms can affect immune responses to vaccines, therefore three doses may still be necessary. The aim of this study was to identify barriers and facilitators associated with uptake of HPV vaccine. Methods: A cross-sectional survey was conducted at Eldoret, Kenya involving 3000 girls aged 9 to 14 years from 40 schools. Parents/guardians gave consent through a questionnaire. Results: Of all 3083 the school girls 93.8% had received childhood vaccines and 63.8% had a second HPV dose, and 39. 1% had a third dose. Administration of second dose and HPV knowledge were both strong predictors of completion of the third dose. Distance to the hospital was a statistically significant risk factor for non-completion (P: 0.01). Conclusions: Distance to vaccination centers requires a more innovative vaccine-delivery strategy and education of parents/guardians on cervical screening to increase attainment of the HPV vaccination

Determinants of acceptance and subsequent uptake of the HPV vaccine in a cohort in Eldoret, Kenya

The development of Human Papillomavirus (HPV) vaccines provides new opportunities in the fight against cervical cancer. Many acceptability studies have revealed a high interest in these vaccines, but acceptance is only a precursor of behavior, and many factors, at the personal, community and provider level, may inhibit the translation of willingness to vaccinate into actual uptake. Through a longitudinal study in Eldoret, Kenya, HPV vaccine acceptability was measured before the implementation of a vaccination program (n=287) and the actual vaccine uptake, as reported by mothers, once the program was finished (n=256). In between baseline and follow-up, a pilot HPV vaccination program was rolled out via the GARDASIL Access Program, in which parents could have their daughter vaccinated free of cost at the referral hospital. The program was promoted at local schools: health staff informed teachers who were then asked to inform students and parents regarding cervical cancer prevention and the vaccination program. Even though baseline acceptance was very high (88.1%), only 31.1% of the women reported at follow-up that their daughter had been vaccinated. The vaccine was declined by 17.7%, while another 51.2% had wanted the vaccination but were obstructed by practical barriers such as a lack of information or time constraints. Being well-informed about the program and baseline awareness of cervical cancer were independently associated with vaccine uptake, while baseline acceptance was correlated in bivariate analysis. Side effects were of great concern, even among those whose daughter was vaccinated. Possible partner disapproval lowered acceptance at baseline, and women indeed reported at follow-up that they had encountered his opposition. In Kenya, women prove to be very willing to have their daughter vaccinated against cervical cancer. However, in this study, uptake was more determined by program awareness than by HPV vaccine acceptance. School-based vaccination might improve coverage since it reduces operational problems for parents. In addition, future HPV vaccination campaigns should address concerns about side effects, targeting men and women, given both their involvement in HPV vaccination decision-making