Parents’ willingness to vaccinate their daughters with human papillomavirus vaccine and associated factors in Debretabor town, Northwest Ethiopia: A community-based cross-sectional study

ABSTRACT

The Human Papilloma Virus (HPV) is the primary causative agent of cervical cancer. Vaccination against the HPV infection is an effective prevention measure for HPV-related diseases. This study aimed to assess parents’ willingness to vaccinate their daughters with Human Papillomavirus vaccine and associated factors in Debre Tabor town. A community-based cross-sectional study was conducted among parents of daughters in Debre Tabor town, and a cluster sampling technique was used to select 738 study participants. A structured and interviewer-administered questionnaire was used to collect the data. Data were entered into EPI data version 4.6 and exported to SPSS version 26 for analysis. Multivariable logistic regression was done and a p-value of ≤ 0.05 was used to declare the level of significance. In this study, parents’ willingness for HPV vaccination was found to be 79.10% (95% CI: 76.00, 82.00). Parents having media exposure, had good knowledge of HPV infection, and HPV vaccine, positive attitude, and positive perceived behavioral control toward the HPV vaccine had statistically significant association with willingness for the HPV vaccination of their daughters. Parents’ willingness to HPV vaccination for their daughters was higher compared with a previous study done in the setting. Parental knowledge and their beliefs on HPV vaccination, and media exposure play an important role in the HPV vaccination of adolescents. Strengthening community-based education and effective promotion through multimedia on HPV infection and its prevention, addressing parental safety concerns and promoting their positive beliefs about the vaccine are important to increase parents’ willingness.

KEYWORDS:

• Ethiopia
• Human Papilloma Virus
• parents
• vaccination
• willingness

Introduction

Globally, cervical cancer is the most commonly diagnosed Gynecologic cancer. It is the second leading cause of mortality and fourth most common cancer in women.^1–3 According to the World Health Organization (WHO), there were estimated 604,000 new cases and 342,000 deaths worldwide in 2020. As to the report, greater than 90% of the mentioned deaths occurred in developing countries, including sub-Saharan Africa (SSA).⁴ In Ethiopia, cervical cancer is the second most common cancer, after breast cancer, and the leading cause of cancer-related deaths. Annually, an estimated number of 4,648 women develops cervical cancer, and 3,235 of them die.⁵

Nearly all (99%) cervical cancer cases are caused by Human Papillomavirus (HPV), of which HPV 16 and 18 types account for 70% of the cases and precancerous cervical lesions.^4,6

Most developed countries have well-organized strategies for the screening, early detection, and effective treatment of precancerous cervical lesions. This allows them to prevent 80% of cervical cancer cases caused by different HPV subtypes. However, in low-resource settings, there are poorly organized efforts to ensure screening and appropriate treatment for eligible women.⁷ As a result, primary prevention through HPV vaccines was suggested to be an effective way to prevent cervical cancer, and the vaccine is safe, well tolerated, and highly effective in preventing persistent infections.⁸

Vaccination could reduce the likelihood of contracting several serious illnesses.⁹ The Human Papillomavirus Vaccine is a primary cancer prevention measure approved for use and now widely available in many countries.⁷ Ethiopia launched the quadrivalent human papillomavirus (4vHPV) vaccine for the first time in December 2018. The vaccine is currently being delivered primarily through a school-based approach to reach all eligible girls.¹⁰

Human papillomavirus vaccines are effective against cervical cancer and able to protect against 90% of HPV infection.^11,12 Likewise, HPV vaccination in adolescents with continued cervical screening could ultimately reduce the chance of death of cervical cancer by 76% and a 50% reduction in cervical screening abnormalities.⁸ However, despite the many benefits of the HPV vaccine, parental willingness and their decision-making largely affect the uptake of the vaccination series and its completion by adolescents.^12–14

As to the previous studies, the prevalence of parental willingness to vaccinate their daughter varies from region to region ranging from 44.8% (Ethiopia) to 95% (Kenya).^15,16 Various factors may influence parental willingness toward the HPV vaccination for their adolescents. Parental age, higher educational level, and monthly income, as well as knowledge, and awareness on cervical cancer, and HPV infection, a positive attitude toward the HPV vaccine, and subjective norms related to important people nearby with regard to vaccination were associated factors for the willingness of HPV vaccine.^3–15–24

Improving the health of adolescents and women and keeping them healthy is the concern of the globe and for Ethiopian governments as well. Although the government and other non-governmental organization (NGO) partners have made great efforts for the improvement of maternal and child health, little attention is given to the HPV vaccination. In addition, evidence reaching out to the willingness of parents on this vaccine is scarce, particularly in the study setting. Therefore, this study aimed to assess the parents’ willingness to vaccinate their daughters with Human papillomavirus vaccine and associated factors in Debre Tabor town, Ethiopia.

Methods

Study design, setting, and period

A community-based cross-sectional study was conducted in Debretabor town, South Gondar zone of Amhara regional state, northwest Ethiopia, from December 15^th to February 15^th, 2021/22. The town is located at a distance of 665 kms away from Addis Ababa (the capital city of Ethiopia) and 98 kms from Bahir Dar (the capital city of the Amhara regional state). The town has six kebeles with an estimated total population of 96,973 based on a population projection of Ethiopia for all regions at the world level in 2017, one referral hospital, three health centers, six health posts, five private clinics, and three preparatory, three high, and five elementary governmental schools.

Source population

All parents/caregivers who have daughters aged from 9 to 14 years in Debre Tabor town.

Study population

All parents/caregivers having daughters in the age group of 9–14 years in the selected kebeles (the smallest administrative unit in the country) and available in the data collection period.

Sample size determination and sampling technique

The sample size for this study was determined by using both the single and double population proportion formulas. The sample size for the first objective was calculated using a single population proportion formula by considering the following assumptions: 81.3% proportion of parental human papillomavirus vaccine acceptance from a previous cross-sectional study done in Gondar,³ a 95% level of confidence, and 5% margin of error, which yielded the sample size of 234. Finally, by considering a design effect of two and a non-response rate of 10%, the final sample size was 515. The sample size for the second objective was calculated using Epi-Info version 7 statistical software using the following assumptions: 95% CI, power of 80%, exposed unexposed ratio = 1, and Crude Odds Ratio (COR = 2.21) by using factors associated with the study’s findings from the same reference,³ which yields a sample size of 316. Accordingly, the largest sample was obtained from the second objective, and by adding a 10% of non-response rate and multiplying by a design effect of 2, the final sample size for this particular study was 696. However, because of the effect of cluster sampling, a total of 738 parents/caregivers were interviewed. Debretabor town has six kebeles, and three kebeles were selected by simple random sampling. The cluster sampling technique was used to select study participants. All eligible parents/caregivers in the selected clusters were interviewed. The available parent/caregiver during data collection time was interviewed, and a lottery method was used if both parents/caregivers were available during the data collection time.

Study variables

The dependent variable was parents’ willingness to vaccinate their daughters with the HPV vaccine.

The independent variables were sociodemographic variables (Age, Sex, Relationship, Religion, Educational Status, Occupation, Average monthly income, Marital status, and Media exposure), reproductive, and other health-related factors (Number of daughters, and Family history of cervical cancer), knowledge status, subjective norm, perceived control, and attitude toward HPV infection and vaccine.

Measurement and operational definitions

Willing for HPV vaccination

The degree to which the participants would voluntarily make an effort to have their children receive the HPV vaccine.²⁵

Parents who scored the mean and above on the summative score designed to assess willingness were considered willing; otherwise, they were not.^25,26

Knowledge

Was assessed by 8 items with ‘Yes’ or ‘No’ response. Parents who scored at or above the mean value on measures of their knowledge about HPV infection and vaccination were categorized as to have good knowledge, otherwise they were considered to have poor knowledge.²⁰

Attitude

Attitude was assessed using 5 Likert scale items ranging from strongly disagree to strongly agree for each attitude measurement items and parents who scored the mean value and above were categorized as having a positive attitude, otherwise a negative attitude.²⁰

Subjective norms

The expectations of individuals from significant or powerful peoples regarding whether to perform a behavior or not.²⁷ The degree of pressure that the participants recognized from important people nearby with regard to vaccination.^18,25 They are important and principal societal impact factors for a person’s attention change on vaccination. Subjective norms are chiefly concerned with an individual’s attention of other individuals` crucial beliefs on specific action. These norms possess a straight consequence on behavioral schemes via intimidating communal provocation.²⁸ In the present study, subjective norms would refer to the extent to which parents’ willingness to vaccinate their daughters with the HPV vaccine is influenced by whether their significant social others approve of them taking the vaccine or not. It was assessed using 5 Likert scale items ranging from strongly disagree to strongly agree for each subjective norm measurement items and parents who scored the mean value and above were categorized as having a positive subjective norm influence, while those who responded less than the mean value were categorized as having a negative subjective norm influence.^18,25

Perceived behavioral control

The ability to perform a behavior. The participants’ perceived difficulty or ease to have the HPV vaccination.^25,27,29 It is a grasped scope and self-rule, which either motivates or obstructs behavioral execution. As to the positive, it boosts self-efficacy and confidence on accomplishing a specified behavioral duty.²⁸ Parents who scored the mean value and above on measurements of perceived behavioral control using 5 Likert scale items ranging from strongly disagree to strongly agree were thought to have positive perceived control, while those who scored below the mean were thought^18,25,29

Media exposure

Those who respond at least once a week to one of the following were considered to be exposed to media (including TV, newspapers, and radio).^30,31

Data collection instrument and procedure

Data were collected using a structured face-to-face interviewer administered questionnaire adapted from similar studies.^{3–15–17–20–22–25,26–29–33} First, the questionnaire was prepared in English and translated to the local (Amharic) language, and then back to English to ensure consistency. Expert opinions were taken for the validities of the measuring instrument, and the internal reliability was checked by Cronbach's alpha, and the values are exceeded to 0.73. Three BSc and one MSc midwifery professional familiar with the local language and customs had participated in the data collection process as data collectors and a supervisor, respectively. A day of training was given for the data collectors and the supervisor to assure language clarity and on the data collection procedures, the content of the questionnaire, interview techniques, and assuring confidentiality of the respondent’s information obtained from them and precautions on COVID-19.

Data quality control

A pretest was done on 5% of the sample size before collecting the actual data to assess clarity of the questionnaire, the level of understanding of data collectors, language clarity, and the appropriateness of the questionnaire. At the end of each day, the questionnaire was reviewed and checked for accuracy and consistency by the supervisor and investigator.

Data processing and analysis

Data were checked, coded, and entered into the EPI Data 4.6 version and exported to SPSS version 26 analysis software. Descriptive statistics were used to present the characteristics of the study participants. A binary logistic regression model was fitted to identify statistically significant independent variables and variables having a p-value of less than 0.25 in the bivariable analysis were proceeded to the multivariable logistic regression to handle the effect of possible confounders. Variables were chosen using the backward likelihood ratio approach in the multivariable logistic regression analysis, and the Adjusted Odds Ratio (AOR) with its 95% CI at a p-value of ≤ 0.05 was used to determine statistically significant association.

Ethical consideration

The ethical approval letter was obtained from the Institutional Review Board (IRB) of the University of Gondar. A formal letter of organizational approval was obtained from the Debre Tabor town health directive office. The participants were then informed of the study’s objectives, the confidentiality of their information and their right to withdraw from the study at any point during data collection. Finally, an informed written consent was obtained from the participants before starting the actual data collection.

Result

Socio-demographic characteristics of study participants

In this study, a total of 721 participants were included, with a response rate of 97.6%. The mean age of respondents was 40.88 (SD ±6.72) years and 56.9% of the participants were within the age group of ≥40 years old. More than half (58.4%) of those who took part in the survey were women and nearly all (99.2%) were their biological parents. Most of the respondents (94.7%) were Orthodox Christian followers by religion. From the study, the majority of the participants (87.1%) were married and as to their educational status, 43% of the participants had completed college and above. Approximately, one-third (34.5%) of the study participants were governmental employees by occupation (Table 1).

Table 1. Socio-demographic, knowledge, attitudes, subjective norms, perceived behavioral control characteristics of study participant in Debre-tabor town, Northwest Ethiopia, 2021/22 (n = 721).

Variables	Category	Willingness		Frequency (%)
		Willing	No willing
Age group of participants in year	≤29	13	5	18 (2.5)
	30–39	239	54	293 (40.6)
	≥40	318	92	410 (56.9)
Sex	Male	237	63	300 (41.6)
	Female	333	88	421 (58.4)
Relation-ship	Father	235	63	298 (41.3)
	Mother	333	84	417 (57.8)
	Other^a	2	4	6 (0.8)
Religion	Orthodox	538	145	683 (94.7)
	Muslim	32	6	38 (5.3)
Current marital status	Single	27	5	32 (4.4)
	Married	506	122	628 (87.1)
	Divorced	24	17	41 (5.7)
	Widowed	13	7	20 (2.8)
Educational status	No formal education	110	71	181 (25.1)
	Primary education	68	25	93 (12.9)
	Secondary education	117	20	137 (19)
	College and above	275	35	310 (43)
Occupation	House wife	149	53	202 (28)
	Merchant	138	46	184 (25.5)
	Government employee	225	24	249 (34.5)
	Self-employee	55	24	79 (11)
	Other^b	3	4	7 (1)
Average monthly income	<2000 ETB	21	5	26 (3.6)
	2000–4000 ETB	180	71	251 (34.8)
	>4000 ETB	369	75	444 (61.6)
Media exposure	Not exposed	18	28	46 (6.4)
	Exposed	552	123	675 (93.6)
Knowledge	Poor	255	134	389 (54)
	Good	315	17	332 (46)
Attitude	Negative	153	125	278 (38.6)
	Positive	417	26	443 (61.4)
Subjective Norm	Negative	167	61	228 (31.6)
	Positive	403	90	493 (68.4)
Perceived behavioral control	Negative	155	118	273 (37.9)
	Positive	415	33	448 (62.1)

Key: ^aGuardians/caregivers, ^bDaily laborer.

Knowledge, attitudes, subjective norms, and perceived behavioral control related characteristics

More than half (54%) of the study participants had inadequate knowledge about the HPV infection and HPV vaccination. On the other hand, 61.4% of parents had a positive attitude toward HPV infection and its vaccination for their daughters. More than two-third (68.4%) and around 62.1% of the respondents had positive subjective norms and perceived behavioral control on HPV vaccination for their daughters, respectively (Table 1).

Reproductive and other health related characteristics

The majority of the study participants (80%) had one daughter between the ages used for this study. Almost all, of the participants in this study (99.2%) had no family history of cervical cancer (Table 2).

Table 2. Reproductive and other health-related characteristics of study participant in Debre-tabor town, Northwest Ethiopia, 2021/22 (n = 721).

Variables	Category	Willingness		Frequency (%)	p - value
		Willing	No willing
Number of daughters	One	460	117	577 (80)	.38
	More than one	110	34	144 (20)
Family member infected with cervical cancer	Yes	5	1	6 (0.8)	.79
	No	565	150	715 (99.2)

Parents’ willingness to HPV vaccination for their daughters

In this study, 79.1% (95% CI: 76, 82) of participants were willing to vaccinate their daughters with the HPV vaccine. The most frequent perceived reasons given by the participants for not vaccinating their daughters were concerns about the vaccine’s safety, followed by not being informed by health care practitioners and believing that no need to vaccinate them (Table 3).

Table 3. Perceived reasons of parents not to vaccinate their daughters for HPV vaccine among parents having daughters aged between 9 and 14 years old in Debre Tabor town, Northwest Ethiopia, in 2021/22.

Perceived reasons of parents	Category	Willingness		Frequency (%)	p - value
		Willing	No willing
Not informed by health care providers	Yes	9	58	67 (56.8)	.19
	No	3	48	51 (43.2)
Worried about safety of the vaccine	Yes	3	83	86 (72.9)	.001
	No	9	23	32 (27.1)
Does not trust on the efficacy of the vaccine	Yes	2	23	25 (21.2)	.69
	No	10	83	93 (78.8)
Do not know where or how to access the vaccine	Yes	5	44	49 (41.5)	.99
	No	7	62	69 (58.5)
May expose adolescents to risky sexual behavior	Yes	1	5	6 (5.1)	.59
	No	11	101	112 (94.9)
Believe no need of vaccinating them	Yes	6	49	55 (46.6)	.80
	No	6	57	63 (53.4)

Factors associated with parental willingness to HPV vaccination for their daughters

In the multivariable logistic regression analysis; media exposure, knowledge status and attitude toward HPV infection and HPV vaccine, and perceived behavioral control on HPV vaccine were the factors that had significantly associated with parents’ willingness to HPV vaccination for their daughters.

In this study, those parents who were exposed to mass media were 2.74 (AOR = 2.74, 95% CI: 1.31, 5.71) times more likely to vaccinate their daughters with the HPV vaccine compared to those who did not utilize media.

Among the respondents, parents with good knowledge on HPV infection and HPV vaccinations were 2.85 times more likely to be willing to vaccinate their daughters against HPV compared with their counterparts (AOR = 2.85, 95% CI: 1.54, 5.29).

In addition, the odds of parents’ willingness to vaccinate their daughters against HPV were 5.10 times higher among parents having a positive attitude toward HPV infection and its vaccination when compared with those with unfavorable attitudes (AOR = 5.10, 95% CI: 3.01, 8.66).

Similarly, this study also revealed that parents who had positive perceived behavioral control toward HPV vaccination were 4.75 times more likely to be willing to vaccinate their daughters with the HPV vaccine as compared to parents having negative PBC (AOR = 4.75, 95% CI: 2.96, 7.60) (Table 4).

Table 4. Logistic regression analysis of factors associated with parents’ willingness for HPV vaccination in Debre Tabor town, northwest Ethiopia, 2021/22 (n = 721).

Variables	Category	Willingness		COR (95% CI)	AOR (95% CI)
		Willing	No willing
Educational status	No formal education	110	71	1	1
	Primary education	68	25	1.76 (1.02, 3.03)	1.16 (0.59, 2.28)
	Secondary education	117	20	3.78 (2.16, 6.61)	1.68 (0.85, 3.32)
	Collage and above	275	35	5.07 (3.19, 8.04)	0.67 (0.27, 1.62)
Marital status	Single	27	5	1	1
	Married	506	122	0.77 (0.29, 2.04)	0.71 (0.21, 2.43)
	Divorced	24	17	0.26 (0.08, 0.82)	0.26 (0.06, 1.16)
	Widowed	13	7	0.34 (0.09, 1.29)	0.67 (0.13, 3.39)
Occupation	House wife	149	53	1	1
	Marchant	138	46	1.07 (0.68, 1.69)	0.87 (0.49, 1.53)
	Government- employee	225	24	3.34 (1.97, 5.64)	1.61 (0.66, 3.95)
	Self-employee	55	24	0.82 (0.46, 1.45)	0.84 (0.4, 1.73)
	Others	3	4	0.27 (0.06, 1.23)	1.88 (0.29, 12.11)
Media exposure	Not exposed	18	28	1	1
	Exposed	552	123	6.98(3.74, 13.02)	2.74 (1.31, 5.71)*
Knowledge	Poor	255	134	1	1
	Good	315	17	9.74 (5.73, 16.56)	2.85 (1.54, 5.29)*
Attitude	Negative	153	125	1	1
	Positive	417	26	13.10 (8.26, 20.78)	5.10 (3.01, 8.66)**
Subjective Norm	Negative	167	61	1	1
	Positive	403	90	1.64 (1.13, 2.37)	1.25 (0.77, 2.01)
Perceived-behavioral control	Negative	155	118	1	1
	Positive	415	33	9.57 (6.24, 14.69)	4.75 (2.96, 7.60)**

**p- value ≤ .001, *p- value ≤ .05.

Abbreviations: AOR= Adjusted odds ratio, COR = Crude odds ratio, CI = Confidence interval.

Discussion

This, a community-based cross-sectional study assessed parents’ willingness to HPV vaccination for their daughters and associated factors among parents of daughters in Debre Tabor town, Northwest Ethiopia. The study revealed that most of the parents were willing to have their daughters vaccinated for the HPV vaccine. Having media exposure, good knowledge on HPV infection and the HPV vaccine, positive attitude, and positive perceived behavioral control toward the vaccine were factors significantly associated with parents’ willingness to vaccinate their daughters with the HPV vaccine.

This study depicted that more than three-quarters (79.1%) of parents were willing to HPV vaccination of their daughters. This is in line with studies done in India, 79.9%,³⁴ Nigeria in different periods, 80.9% and 82%,^21,35 and Ethiopia; Gondar town 81.3%,³ and Bench-Sheko zone, 79.5%.²⁰ This may be due to the similarity in some of the socio-demographic characteristics, such as the marital and educational status of participants. From studies done in India and Nigeria, the majority (91.5%,³⁴ and 84.4%²¹ of the study participants were married, respectively, and around 50% had accomplished college and above to their educational level,²¹ which is almost similar to this study’s finding. This can be explained by being in a relationship and level of education significantly increases the acceptance and vaccination of HPV vaccine.^20,21,36 Therefore, educational programs on HPV prevention should be designed targeting those who are single and have a lower level of education, thereby increases parents’ willingness to the vaccination of their daughters.

In this study, parents’ willingness to HPV vaccination for their daughters was higher than studies conducted in the USA, 42%, Argentina, 59.88%, Nigeria, 44.9%, and Ethiopia, 44.8%, respectively.^13,16,18,19 This variation could be due to the differences in study setting and period, study population, and the data collection method. Most of the aforementioned studies were school-based, and the study from Nigeria included only mothers as the study participants. However, the current study was community-based, and all parents were included. Data were collected via phone in a study conducted in the United States, which might have a higher rate of nonresponse, less cooperation, and less success in obtaining in-depth responses from the person being interviewed in comparison to the current study’s face-to-face interview.³⁷ Moreover, not all candidate individuals might have been included because some people in the population would not have phones or would not answer when the calls were made. The study period may also be the other logic for the difference. There is a time period gap in most of those the above-mentioned studies and as a result, as time runs, the health system and care setups become better that could inter increase parental awareness on the vaccination.

However, the finding of the present study is lower than a study conducted in China, Hong Kong, 87%.²³ The possible discrepancy might be the difference in study population and study setting that the above-mentioned study was institutional based and included school-aged students between 9 and 14 years with their parents and educational videos and materials were provided for them before the actual data collection. This could be explained by the fact that students may have had a better understanding of HPV infection and its primary prevention method, vaccination, from their teachers, and the informative materials provided prior to the data collection period, which may add up the parents’ willingness to get the vaccination as well. This result is likewise lower as compared to studies done in Poland, 85.1%³² and Thailand, 85%.³⁸ One possible variation might be the study setting, that it was institutional (a school) based on parent-teacher meetings in which the study participants might have a discussion opportunity with school teachers about the health of their children in general and the benefits of the HPV vaccine in particular. Parents filled out the questionnaires in the presence of teachers from a study done in Poland, that there might also be a response bias in the study, and thus might have given more socially desirable responses.³⁹ Similarly, parental willingness in this study is lower than studies conducted in Nigeria, 96.5%,⁴⁰ 89.1%,⁴¹ Kenya, 95%,¹⁵ northwest Ethiopia, 85.9%,⁴² and Addis Ababa, 94.3%.⁴³ This difference might be due to the difference in study setting and some socio-demographic factors from a study in Kenya. The study was institutional based at teaching and referral gynecological care women in which study participants might have a chance of discussion with their healthcare providers on the risk of cervical cancer, its complications, and preventive methods during their gynecological evaluation for them and for their daughters as well. In the above-mentioned study, more than 70% of the study participants had accomplished tertiary and above as to their level of educational status in which only 43% in the current study there by having higher educational level of participants might have better understanding on children’s health. The difference in a study from northwest Ethiopia might be due to the difference in study population that healthcare providers were the study participants, unlike parents in the current study. Thus, healthcare providers may have a better understanding and knowledge of HPV infection and the benefits of the vaccine.⁴² The other difference, a study from Addis Ababa, might be due to study participants’ residency that their study participants were living from the capital city of the country with greater access to health-related information and expected a better level of health literacy and understanding as compared to other parts of the country.

The present study identified that media exposure was significantly associated with parents’ willingness to the HPV vaccine. Those parents who were exposed to media were 2.74 times more willing to have their daughters vaccinated with the HPV vaccine than those who did not. This finding is consistent with studies from Canada, China, and Ethiopia in Jimma.^44–46 This could be plausibly explained as mass-medias are a means of information dissemination, health education, and awareness creation for the whole community. Therefore, it is uppermost important to promote about HPV vaccine through media to increase the vaccine acceptance by doing so increases the uptake in the future.

The findings of this study also showed that knowledge on HPV infection and HPV vaccine was significantly associated with parental willingness to have their daughters to be vaccinated for it. The odds of being willing to HPV vaccine were 2.85 times higher among parents having good knowledge as compared to their counterparts. In addition, despite not having adequate knowledge about cervical cancer prevention, the majority of the parents were willing to have their daughters vaccinated with the HPV vaccine. This is supported by studies done in Poland,³² Malaysia,⁵⁵ Nigeria,^19,21 Kenya,¹⁵ and Ethiopia.^3,16,20 This might be probably because, due to the seriousness of the disease and people’s fear of developing cancer, parents might seek to protect their daughters from cervical cancer that knowledge of parents to HPV infection and its vaccination is an important factor in the vaccination of their daughters.¹⁹ Knowing the risks and complications of the HPV virus, and the advantages of its vaccination plays an important impute in parents’ acceptance of the vaccine.⁴⁷ Thus, to promote HPV vaccination of daughters in the study area, parental awareness-raising programs should focus on its mechanisms of transmission, ability to cause cancer, and the fact that cervical cancer can be prevented by HPV vaccination.

Consistent with previous studies,^{3,15,18,20,31,43} this study revealed that a positive attitude toward HPV and its vaccination was significantly associated with parents’ willingness to vaccinate their daughters with the HPV vaccine. Parents who had a positive attitude toward HPV infection and its vaccination were 5.10 times more willing to the HPV vaccine for their daughters when compared with parents who had unfavorable attitudes. This could be explained by the fact that parents’ views and opinions about the efficiency of all recommended vaccines in general, and the HPV vaccine in particular, play a big role in vaccine acceptance. Other more possible explanation could be due to the widespread belief that cancer is a serious and fatal disease.²¹ Acceptance of the HPV vaccine is heavily influenced by parental attitudes. Therefore, filling up gaps through public health education programs for parents with a negative attitude to the HPV vaccine would result in a high vaccine acceptance thereby increases the vaccine uptake in the running.

Lastly, the study revealed that parents with positive perceived behavioral control toward the HPV vaccine were able to express their intention to obtain the HPV vaccination for their daughters. The odds of willing to HPV vaccine were 4.75 times higher among parents having a positive PBC than parents having negative PBC for HPV vaccination. This is supported by studies done in Italy, Nigeria, Taiwan, and Indonesia.^29,31,40,48 This result might suggest that the perceived difficulties in arranging the vaccination program outside of a school-based system due to financial, transportation, or time constraints. In the same way, without considering the cost of the vaccine as a barrier, parents will decide whether or not their daughters can get the vaccination that providing the vaccination for free enhanced parents’ perceived control.⁴⁸ Moreover, parents have confidence in their ability to determine whether to endorse the HPV vaccine for their daughters. Indeed, administering the HPV vaccine at the community level in village based will ease the acceptance of the vaccine and the uptake as well.

Limitation of the study

Social desirability bias could be present in the study. However, in order to decrease such bias, participants were first told in detail about the purpose of the study and how the data would be handled to maintain confidentiality. In addition, they were thoroughly briefed on their participation, which can have a critical influence in the study’s outcomes.

Conclusion

The study has shown that parents’ willingness to have their daughter receive HPV vaccination was high, and the acceptance was significantly associated with media exposure, the level of knowledge on HPV infection and the vaccine, the attitude, and perceived behavioral control toward the vaccination. So, strengthening community-based education and effective promotion through multimedia on cervical cancer, HPV infection, and its prevention and addressing parental safety concerns and promoting their positive beliefs about the vaccine are important to increase parents’ willingness.

Abbreviations

HPV	=	Human papilloma virus
U.S.A	=	United States of America
WHO	=	World health organization
PBC	=	Perceived behavioral control

Author’s contributions

GM: Writing the original draft, designed the study, statistically analyzed and interpret the data, prepared, reviewing and editing the manuscript. GL: Preparing the manuscript, reviewing, editing the manuscript and critically reviewed the article. MA: Reviewing and editing the manuscript. TA: Statistically analyzed and interpret the data, reviewing, editing the manuscript and critically reviewed the article. SA: Preparing the manuscript, reviewing, editing the manuscript and critically reviewed the article. All the authors made a significant contribution in the conception and designing the study, acquisition of data, analysis, interpretation and revising critically. All authors took part in drafting, revising, and gave final approval of the version to be published and agreed to be accountable for all aspects of this work.

Acknowledgments

We would like to acknowledge the University of Gondar, College of Medicine and Health Sciences for providing us an ethical clearance and financial support to do this thesis. Also, we would like to express our deep appreciation to data collectors, supervisor, Debre Tabor town health office, and study participants.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This study was funded by the University of Gondar. The funding organization was not involved in study design, data collection, data analysis, report writing, nor the publication.