Mothers’ intention to vaccinate their daughters against human papillomavirus in NorthWest Ethiopia, using the theory of planned behavior

ABSTRACT

Human papillomavirus (HPV) is the second most common cause of cancer worldwide among females. HPV vaccination is highly protective against HPV infection and can reduce 56% of HPV infections. Therefore, the study aims to assess mothers’ intention to vaccinate their daughters aged 9–14 years old against human papillomavirus in Debre Tabor town, Northwest Ethiopia, using the theory of planned behavior. A community-based cross-sectional study design was employed using the theory of planned behavior from November 1 to 30, 2022, in Northwest Ethiopia. A total sample of 449 study participants was enrolled. The study participants were selected using a multi-stage random sampling technique. Data was collected using an interview-administered questionnaire. The data was entered into EPI data version 4.6 and then, exported to SPSS version 23 for analysis. Those variables with a p-value <.05 with 95% CI were considered significant predictors. Mothers’ positive intention to vaccinate their daughters aged 9–14 years against HPV was 67.5%. Attitude, perceived behavioral control, and subjective norm were significant predictors with (AOR = 10.09, 95% CI = 6.23–16.32), (AOR = 4.12, 95% CI = 2.71–6.26), and (AOR = 16.397, 95% CI = 9.69–27.748), respectively. Only two-thirds of mothers have a positive intention to vaccinate their daughters against human papillomavirus. Attitude, perceived behavioral control, and subjective norm were predictors. Therefore, it is better to do community mobilization toward the advantage of HPV vaccination.

KEYWORDS:

• HPV
• intention
• theory of planned behavior
• Debre Tabor
• Ethiopia

Introduction

Human papillomavirus (HPV) is a double-stranded deoxyribonucleic acid virus that belongs to the family of Papillomavirus.¹ Genotypically, there are more than 100 different variants of HPV globally. Based on their risk for causing cancer, HPV Geno types are divided into low-risk and high-risk Geno types. Among the low-risk Geno types, HPV-6 and −11 Geno types are the majority for causing benign lesions that affect the Ano-genital areas, such as genital warts, while Geno types HPV-16 and -18 are high-risk Geno types for causing cervical cancer. Infection by these high-risk genotypes is responsible for up to 99.7% of cervical cancer cases.^2,3

Regarding low and high impact, the non-valent vaccination showed a significant potential impact (29.7% > 18.:8% and 34:6% > 26.6%, respectively) when compared to the quadrivalent.¹ Potential effects ranged from 56.9% to 81.0% for high squamous intraepithelial lesions (HSIL) and from 30.9% (low estimate) to 53.3% (high estimate) for low squamous intraepithelial lesions (LSIL).⁴

Australia is the first country to appliance a government-funded, population-based HPV vaccination program.⁵ China approved the first HPV vaccine in 2016. China does not currently have a national HPV vaccination program that offers free or inexpensive HPV vaccinations.⁶ Although recommended for all member states of WHO, HPV vaccination has not been implemented in Kazakhstan yet.⁷ In Ethiopia, the vaccine was launched in 2018; recently, the vaccine was given for 9–14-year-old females in two doses at 6-month intervals.⁸

HPV is a major cause of cancer development.⁹ Approximately 84% of all cervical cancers and 88% of all deaths caused by cervical cancer occurred in low-resource countries. Around 5000 women were found to have HPV infection each year, while around 3000 women die from this disease.¹⁰ Cervical cancer is the fourth leading cause of death after breast, lung, and colorectal cancers. The highest burden of cervical cancer was observed in southern Africa and eastern Africa. In 2018, approximately 570,000 new cases, and 311,000 deaths happened.¹¹ In sub-Saharan Africa, HPV infection accounts for 22.5% of all cancer cases in women.¹² Estimated 22 million Ethiopian women between the ages of 15 and 49 are affected by cervical cancer each year, with 7095 cases and 4732 fatalities.¹³ The prevalence of cervical cancer in the Amhara region is 15% to 17% increasing as seen in the report in 2019.^10,14

Lack of proper education and knowledge on the risks of HPV, the benefits of HPV vaccination, and the effects of not becoming vaccinated could lead to lifelong exposure to cervical cancer.¹⁵ Over 80% of the deaths were reported at a late stage, primarily due to a lack of awareness and poor knowledge of cervical cancer and inadequate preventive services leading to a poor prognosis.¹² The Tikur Ambessa (Black Lion) Specialized Hospital, the nation’s only oncology facility, reports that over 80% of the cases of cancer are identified at advanced stages when there is little to no chance of recovery. This is mostly because of insufficient resources for early cancer detection and treatment, insufficient screening facilities, a lack of knowledge about the warning signs and symptoms of cancer, and poorly designed referral networks.¹⁶

It is prevented through vaccination, early detection and treatment, proper condom use, and limited sexual partners.¹⁷ Vaccinating females from 9 to 14 years was the most cost-effective public health intervention against HPV because the vaccine targets girls who have not started their sexual debut.^14,15 HPV vaccination is appropriate for controlling and preventing the incidence, prevalence, morbidity, and mortality of cervical cancer in all health systems.¹⁸ Carrageenan (CG), which acts through a variety of processes that are currently unclear, seems to be a promising treatment for HPV infection. It inhibited infection by mucosatropic high-risk papillomaviruses when applied as a vaginal microbicide.¹⁹

Studies suggest that parental attitudes influence adolescent attitudes related to intent to receive the HPV vaccine.²⁰ In the study done in Fujian Province, Chinese mothers stated that among mothers who did not intend to vaccinate their daughters, the three most common reasons were the daughter being too young to receive HPV vaccination (40.6%), fear of side effects (31.9%) and vaccine price being too high (16.0%).⁶

The theory of planned behavior (TPB) was used to know predictors of intentions of a behavior.²¹ Research done in the United States, Ireland, and China revealed that only 59.2%, 68.1%, and 55% had good intentions about the HPV vaccine, respectively.^9,22,23 The study in Dutch indicated that perceived behavioral controls are the most important determinant of HPV vaccination intentions.²⁴ However, the study conducted in China revealed that subjective norm influences a mother’s self-efficacy (comfort and confidence) and intentions to HPV vaccination.²²

There is a limited study done in our country on the intention of HPV vaccination. Therefore, this study aims to assess mothers’ intention to vaccinate their daughters aged 9–14 years against HPV in Debre Tabor town, NorthWest Ethiopia, using the theory of planned behavior.

Methods and materials

Study design and period

A community-based cross-sectional study designed with the theory of planned behavior was conducted on mothers’ intention to vaccinate their daughters aged 9–14 years against HPV in Debre Tabor town, Northwest Ethiopia, from November 1 to 30/2022. The STROBE guideline for cross-sectional studies was followed.

Study area

The study was conducted in Debre Tabor town. Debre Tabor town is the capital city of South Gondar Zone in Amhara region, Ethiopia, which is 105 km away from Bahir Dar, the capital city of Amhara region, and 667 km away from Addis Ababa, the capital city of Ethiopia, in North West, Ethiopia. Based on the 2016 national census stated by the Central Statistical Agency of Ethiopia population projection and the Debre Tabor town plan office, the total estimated population of the town was 55,596 males and 27,644 females with 27,952 and 36,285 households, respectively. It is also structured into 6 Kebeles (kebele 01 up to kebele 06), 3 public health centers, 6 health posts, and 1 specialized hospital (Source: - Debre Tabor town plan office and zonal health office report).

Populations

Source population

All mothers who have daughters in Debre Tabor town.

Study population

Mothers who have the age of 9–14 years daughters in Debre Tabor Town.

Eligibility criteria

Inclusion criteria

All mothers who have 9–14 years of daughters in the selected kebeles in the study period in Debre Tabor town.

Exclusion criteria

Mothers who were severely ill and unable to communicate for different reasons were excluded.

Variables

Dependent variable

• Intention of mothers toward HPV vaccination

Independent variables

• Socio-demographic characteristics (age in years, marital status, religion, residence, occupation, number of 9-14 yrs daughters in a house, income, and educational status).

• Knowledge, attitude, subjective norm, and perceived behavioral control

Operational definitions

Behavioral intention

Behavioral intention is universally defined as a person’s readiness to engage in a certain behavior. This is measured by using a 5-point scale. Persons' behavioral beliefs about the likelihood that the performance of the behavior would result in certain outcomes are measured on bipolar “disagree” - “agree.” It is measured by 6-item intention questions and categorized as ”good intention” (greater than the median) and ”poor intention” (less than the median).²⁵

Knowledge

Knowledge means knowing about HPV vaccination. It is described as good knowledge and poor knowledge; Knowledge scores were computed by giving 1 for participants who correctly answered the questions and 0 for those who did not. It was measured using 11-item knowledge questions and categorized as “poor knowledge” (less than the median), and “good knowledge” (greater than the median).

Attitude

Attitude is generally described as a person’s overall belief that a behavior is ‘positive’ or ‘’negative’. It is measured by using a 5-point scale. A person’s attitude about the likelihood that performances of the behavior result in certain outcomes is measured on bipolar “disagree”- “agree” scales. It is measured by 11-item attitude questions and categorized as ”positive attitude” (greater than the median) and ”negative attitude” (less than the median).²⁵

Perceived behavioral control

It is the motivational factor that can perform a specific activity. Ratings are made based on bipolar agree-disagree scales.

Subjective norm

The subjective norm is defined as the amount of social pressure that an individual perceives. Measured using a single item, asking the person to rate their behavior. Ratings are made based on bipolar “agree”- “disagree” scales.

Sample size determination

The sample size was calculated using a single population proportion formula, assuming a 77% positive attitude toward HPV vaccination intention done in Debre Markos town with a 95% confidence interval (CI), 5% marginal error (d), and 1.5 design effect. This gives the sample size of 408. Adding a 10% non-response rate the final sample size was 449.

N = (Za/2)²/d² p (1-p) (design effect) n = ((1.96)2 (0.77) (0.23) (1.5))/(0.05)2 = 408, Nf = 449, where n = sample size, Nf = final sample size, p = population, z α/2 = 1.96, d = marginal error = 0.05, Design effect = 1.5, the final sample size was 449.

Sampling technique and procedure

A multistage sampling technique was used to select the study participants from Debre Tabor Town. In the study area, there are six⁶ Kebeles. Taking two Kebeles (02 and 04) and then proportional allocation was done to each kebeles to determine the sample size. The proportional allocations of the two kebeles were 33%. Those two kebeles were selected from other kebeles based on their total population size. Among those 9–14 yrs. daughters were 1150 and their mothers also were 1150 and the two selected kebeles were counted and registered by health extension workers and health development armies. The total sample size taken from the total kebeles was 449. Lastly, the households were selected with mothers who have 9–14-year-old daughters by a simple random sampling method. Then, home-to-home visits were used to get mothers who fulfilled the inclusion criteria. Data collectors were visited three times in each home if the mother was absent from her home to minimize the non-response rate (Figure 1).

Figure 1. Schematic sampling procedure.

Data collection tools

Structured interview-administered questionnaire was used to collect the data. Three³ clinical nurses were data collectors and one supervisor qualified with a BSc degree who lives in Debre Tabor town was assigned. The questionnaire consists of socio-demographic characteristics knowledge, intention, attitude, subjective norm, and perceived behavioral control. The questionnaire was initially prepared in English and translated into Amharic and again back to English by professional translators to check for any inconsistencies.

Data quality assurance and management

Two days of training were given to supervisors and data collectors by the principal investigator. The questionnaire was pre-tested and checked on 5% of the sample size from non-actual study areas (Woreta town). The supervisor and principal investigator performed immediate supervision on a daily basis. Each questionnaire was checked for completeness and the principal investigator controlled the overall data collection process.

Data processing and analysis

After data collection, each questionnaire was given a code. The data was assembled from questionnaires and the responses were entered into EPI data version 4.6; then, the entered data was cleaned for errors before data analysis. The collected data was entered into EPI data version 4.6, and analysis was done using the SPSS version 23 software. Descriptive statistics was used to describe the percentage and number of distributions of the respondents based on socio-demographic characteristics and other relevant variables in the study. Logistic regression was used to fit the data to know factors associated with the intention of HPV vaccination. Binary logistic regression was fitted to identify candidate variables for the multi-variable binary logistic regression model. Those variables that had a p-value <.25 in the bivariable model were fitted into the multivariable model and those variables that had a p-value <.05 with its 95% CI were considered statistically significant predictors of the intention to HPV vaccine. The crude and adjusted odds ratios together with their corresponding 95% confidence intervals was computed. A p-value of <.05 and adjusted odds ratio with corresponding 95% confidence intervals were considered statistically significant in this study. The goodness-of-fit was checked by Hosmer Lemeshow’s test and a p-value greater than .05 was considered as a fit model.

Results

Socio-demographic characteristics of the participants

A total of 449 study participants with a response rate of 100% were included in this study. The mean age of the respondents was 38.4 years and the majority of the mothers 367 (81.7%) had one daughter aged 9–14 years in the household (Table 1).

Table 1. Socio-demographic characteristics of mothers’ intention to vaccinate their daughters aged 9–14 years against HPV in Debre Tabor town, NorthWest Ethiopia, 2022 (n = 449).

Variables	Category	Frequency	Percent
Age in years	21–30 31–40 41–50 >50	215 130 96 8	47.9 30.8 21.3 1.9
Marital status	Married Divorce Widowed	415 26 8	92.4 5.8 1.8
Residence	Urban Rural	445 4	99.1 0.9
Religion	Orthodox Muslim Protestant	361 72 16	80.4 16 3.6
Educational status	No formal education Primary school completed Secondary school completed Diploma and above	312 61 11 65	69.5 13.6 2.4 14.5
Occupation	Government employee Private employee Housewife Daily labor Farmer	67 11 278 23 70	14.9 2.4 61.9 5 15.6
Number of 9–14 years daughters in a house	One More than one	367 82	81.7 18.3
Average family income in Ethiopian Birr	1000–2000 2001–3000 3001–4000 >4001	26 84 114 223	5.8 19 25.4 49.8

Knowledge about the HPV vaccine

About 271 (60.4%) of the respondents have poor knowledge about the HPV vaccine. 105(23.4%) of respondents know that Cervical Cancer (CC) is a disease of the genital tract, and about 89 (19.8%) of mothers know that HPV can cause CC (Table 2).

Table 2. Knowledge about mothers’ intention to vaccinate their daughters aged 9–14 years against HPV in Debre Tabor town, NorthWest Ethiopia, 2022 (n = 449).

Items of knowledge questions	Response
	Yes	No
Ever heard about HPV infection and HPV vaccination	133(29.6%)	316(70.4%)
Know HPV infection is preventable	128(28.5%)	321(71.5%)
Know HPV is transmitted by sexual contact	126(28.1%)	323(71.9%)
Know the HPV vaccine against HPV infection	111(24.7%)	338(75.3%)
Knowing the HPV vaccine is recommended before starting sexuality	113(25.2%)	336(74.8%)
Knowing the HPV vaccine is recommended to prevent HPV in the future	91(20.3%)	358(79.7%)
Know HPV is a disease of the genital tract	105(23.4%)	344(76.6%)
Know HPV vaccine recommended for 9–14 years daughters	109(24.3%)	340(75.7%)
Know HPV can cause cervical cancer	89(19.8%)	360(80.2%)
Know HPV vaccine requires two rounds during vaccination	111(24.7%)	338(75.3)
Know HPV vaccine cannot cause infertility	86(24.7%)	363(80.8%)
Know HPV vaccine is given in school	82(10.8%)	367(81.7%)

Source of information

Of the respondents, 133 (29.6%) heard about the HPV vaccine and HPV infection, of whom 92 (68.7%) said, the media was their main source of information about the HPV vaccine.

Attitude towards HPV vaccine

The majority of the participants 331 (73.7%) had negative attitudes toward the HPV vaccine. Of all study participants, 342 (76.2%) believed that HPV vaccination helps prevent HPV infection (Table 3).

Table 3. Attitude toward mothers’ intention to vaccinate their daughters aged 9–14 years against HPV in Debre Tabor town, NorthWest Ethiopia, 2022 (n = 449).

Items of behavioral beliefs question	Response	Frequency	Percent
If my daughter receives HPV vaccine, she will prevent HPV infection	Strongly agree Agree Neutral Disagree Strongly disagree	28 342 5 68 6	6.2 76.2 1.1 15.1 1.3
If my daughter receives the HPV vaccine, she will have well healthy	Strongly agree Agree Neutral Disagree Strongly disagree	28 331 6 78 6	6.2 73.7 1.3 17.4 1.3
If my daughter receives HPV vaccine, she will not have to get HPV vaccine complication	Strongly agree Agree Neutral Disagree Strongly disagree	37 325 7 74 6	8.2 72.4 1.6 16.5 1.3
If my daughter receives HPV vaccine, she will have HPV vaccine side effect	Strongly agree Agree Neutral Disagree Strongly disagree	26 340 8 70 5	5.8 75.7 1.8 15.6 1.1%
If my daughter receives the HPV vaccine, she will be treated for HPV infection	Strongly agree Agree Neutral Disagree Strongly disagree	31 312 3 96 7	6.9 69.5 0.7 21.4 1.5

Indirect attitude measurement

Intention towards HPV vaccination

More than two-thirds of the participants, 303 (67.5%) had good intentions about the HPV vaccine (Table 4).

Table 4. Intention toward mothers’ intention to vaccinate their daughters aged 9–14 years against HPV in Debre Tabor town, NorthWest Ethiopia, 2022 (n = 449).

Items of intention assessment questions	Response	Frequency	Percent
I intend to receive the HPV vaccine for my daughter	Strongly agree Agree Neutral Disagree Strongly disagree	63 282 11 66 27	14 62.8 2.5 14.7 6
My daughter will take the HPV vaccine to prevent HPV infection	Strongly agree Agree Neutral Disagree Strongly disagree	39 238 9 155 8	8.7 53 2 34.5 1.8
My daughter wants to receive the HPV vaccine for her health issues	Strongly agree Agree Neutral Disagree Strongly disagree	31 344 7 63 4	6.9 76.6 1.6 14 0.9
I have decided, my daughter to receive the HPV vaccine	Strongly agree Agree Neutral Disagree Strongly disagree	46 382 4 15 2	10.3 85 0.9 3.3 0.5

Subjective norms of participants for HPV vaccination

More than two-thirds of the participants, 337 (75.1%) had subjective norms toward the HPV vaccine. A total of 345 (76.8%) of the participants agreed that their daughters should have the HPV vaccine, along with 341 (75.9%) of the fathers and 327 (72.5%) of the friends (Table 5).

Table 5. Subjective norms of mothers’ intention to vaccinate their daughters aged 9–14 years against HPV in Debre Tabor town, NorthWest Ethiopia, 2022 (n = 449).

Items of Normative beliefs assessment questions	Response	Frequency	Percent
A. Normative Beliefs
My mother thinks, my daughter should receive the HPV vaccine	Strongly agree Agree Neutral Disagree Strongly disagree	36 345 5 56 7	8 76.8 1.1 22.5 1.6
My father thinks, my daughter should receive the HPV vaccine	Strongly agree Agree Neutral Disagree Strongly disagree	26 341 7 69 6	5.8 75.9 1.6 15.4 1.3
My friends think, my daughter should receive the HPV vaccine	Strongly agree Agree Neutral Disagree Strongly disagree	31 327 11 72 8	6.9 72.8 2.4 16 1.8
Other members of my family think, my daughter should receive the HPV vaccine	Strongly agree Agree Neutral Disagree Strongly disagree	17 345 6 75 1.3	7.4 63 1.8 24.9 2.9
B. Motivation to comply
Items of motivation to comply with assessment questions
My mother approves of receiving the HPV vaccine is important to my daughter	Not very much Not much Neutral Much Very much	12 89 6 332 10	2.7 19.8 1.3 73.9 1.3
My father approves of receiving the HPV vaccine is important to my daughter	Not very much Not much Neutral Much Very much	15 62 4 355 13	6.9 16.6 0.9 79.1 2.9
My friends approves of receiving the HPV vaccine is important to my daughter	Not very much Not much Neutral Much Very much	16 56 5 349 23	3.6 12.5 1.1 77.7 5.1
Other members of my family approve of receiving the HPV vaccine is important to my daughter	Not very much Not much Neutral Much Very much	14 45 6 360 24	3.1 10 1.3 80.2 5.3

Perceived behavioral control of participants for HPV vaccination

More than two-thirds of the participants, 290 (64.6%) had perceived behavioral control toward the HPV vaccine. Out of all participants, 227 mothers (58.6%) agreed that their daughters would receive the vaccine if they had an HPV infection (Table 6).

Table 6. Perceived behavioral control of participants toward mothers’ intention to vaccinate their daughters aged 9–14 years against HPV in Debre Tabor town, NorthWest Ethiopia, 2022 (n = 449).

Items of questions	Response	Frequency	Percent
A. Control Beliefs
If I am doubtfulness, my daughter will not receive the HPV vaccine	Strongly agree Agree Neutral Disagree Strongly disagree	31 316 7 89 6	6.9 70.4 1.6 19.8 0.3
If my daughter had cached HPV infection would receive the HPV vaccine	Strongly agree Agree Neutral Disagree Strongly disagree	26 227 7 182 7	5.8 58.6 1.6 40.5 1.6
If my daughter is sick, she will not receive HPV vaccine	Strongly agree Agree Neutral Disagree Strongly disagree	21 321 9 90 8	4.7 71.5 2 20 1.8
The long distance from home to the health center makes it difficult for my daughter to take the HPV vaccine	Strongly agree Agree Neutral Disagree Strongly disagree	20 327 6 85 11	4.5 72.8 1.3 18.9 2.4
B. Perceived Power
Items of perceived power assessment questions
Lack of support from my family makes it difficult for my daughter to receive HPV vaccine	Strongly agree Agree Neutral Disagree Strongly disagree	22 304 6 110 7	4.9 67.7 1.3 24.5 1.6
Lacks of reminder make my daughter difficult to receive the HPV vaccine	Strongly agree Agree Neutral Disagree Strongly disagree	22 290 8 123 6	4.9 64.6 1.8 27.4 1.3
Lakes of knowledge about the HPV vaccine makes my daughter difficult to receive HPV vaccine	Strongly agree Agree Neutral Disagree Strongly disagree	20 280 7 136 6	4.5 62.4 1.6 30.3 1.3
Healthcare workers’ skills make it difficult to receive the HPV vaccine	Strongly agree Agree Neutral Disagree Strongly disagree	27 82 5 326 9	6 18.3 1.1 72.6 2

Factors of mothers’ intention to vaccinate their daughters aged 9–14 years against HPV

This study revealed that mothers who have positive attitudes toward the HPV vaccine were about 10 times more likely to have good intentions about HPV vaccinations than mothers who had negative attitudes (AOR = 10.088, 95% CI = 6.236–16.319) mothers who have subjective norms were about 16 times more likely to have good intentions about HPV vaccinations (AOR = 16.397, 95% CI = 9.69–27.748).

Mothers who have perceived behavioral control were about four times more likely to have good intentions about HPV vaccinations (AOR = 4.119,95% CI = 2.708–6.264) (Table 7).

Table 7. Results of a bivariate and multivariate analysis on factors of mothers’ intention to vaccinate their daughters aged 9–14 years against HPV in Debre Tabor town, NorthWest Ethiopia, 2022 (n = 449).

Variables	Category	Intention	COR (95% CI)	AOR (95% CI)
Age	21–29 30–39 40–49 ≥50	56 230 152 11	0.099 0.606 0.589 0.262	1.104 1.833 1.802 1.300
Marital status	Married Divorced Widowed	449 21 9	1.022 0.73 0.739	2.799 1.136 0.800
Religion	Orthodox Muslim protestant	361 72 16	0.340 0.288 0.511	1.406 0.751 1.667
Occupation	Government employee Private employee housewife Farmer Daily labored	67 11 278 70 23	0.434 0.267 0.115 0.539 0.321	0.648 0.766 1.112 0.853 0.733
Educational status	No formal education	312	0.702	2.018
	Primary school Secondary school Diploma and above	61 11 65	0.286 0.036 0.250	1.331 0.967 1.241
Number of daughters	One More than one	367 82	0.728 0.350	2.071 1.342
Average monthly income in Ethiopian Birr	1000–2000 2001–3000 3001–4000 ≥4001	26 84 114 223	0.269 0.374 0.399 0.542	1.309 1.454 1.490 1.720
Residence	Urban Rural	4 445	1.846 1.099	6.336 0.333
Source of information	Media Parents Friends	302 119 28	4.452 2.283 2.463	12.451 9.805 11.744
Attitude	Positive attitude Negative attitude	118 331	2.311 0.863	10.088* 0.422
Subjective norms	Normative belief Motivation to comply	112 337	2.797 1.550	16.397* 4.712
Perceived behavioral control	Control belief Perceived power	155 294	1.462 0.113	4.119* 0.893

AOR = Adjusted odds ratio, COR = Crude odds ratio, CI = Confidence interval, * = statistically significant at p-value <.05.

Discussion

This study showed more than two-thirds of participants (67.5%) had positive intentions to vaccinate their daughters aged 9–14 years against human papillomavirus. This finding was lower when compared to a study done in China (78.3%),²² Fujian Province (83.3%),⁶ and the United States (79.8%).²³ This difference may be due to globalization being beneficial to the Chinese and American communities and making it simple to spread awareness about the HPV vaccination. The reason for the high intention in Fujian province was higher maternal education and their understanding of perceived benefits and barriers.

Mothers who have a positive attitude about the HPV vaccine were 10 times (AOR = 10.088; 95% CI = 6.236–16.319), more likely to have good intentions about the HPV vaccinations when compared to those mothers who had negative attitudes which is lower than a study done in the United States.²³ This may be due to more than two-thirds (76.2%) of respondents believing that the HPV vaccine prevents HPV infection. This supported the idea that understanding the purpose of the HPV vaccine could lead to a change in behavior. This finding was also supported by a study done in Ambo town, Oromia, Ethiopia, showed that the odds of HPV vaccine uptake were two times higher among adolescents who had a positive attitude toward the vaccine.²⁶ Moreover, 73.7% of the participants had negative attitudes toward the HPV vaccine. This finding was more than a systemic review done in China (36%),²² Kazakhstani (46%),²⁷ and the study in the United States (41%).²³ A discrepancy in the vaccine’s application methods could be the cause of this difference. The HPV vaccine is administered routinely in medical facilities in both China and the United States, along with other vaccines. When we see the vaccine application in Ethiopia, only the outreach program administers the immunization in schools. This finding was higher than the study done in Kazakhstan, 47% of the mothers who had negative attitudes toward HPV vaccination.⁷ This may be due to the fact that in Kazakhstan, parental consent is required for medical interventions for children under 18 years.

Mothers who have subjective norms about the HPV vaccine were about 16 times (AOR = 16.397; 95% CI = 9.69–27.748), more likely to have good intentions about the HPV vaccinations. It supports also a study done in the United States (48.7%).²³ These data might support the idea that having subjective norms will affect an individual in a certain manner and their motivation to comply with those people’s views. Furthermore, 75.1% of the participants had subjective norms about the HPV vaccine. This finding was higher than studies done in China (56%)²² and the United States (61%).²³ The reason for this difference might be a difference in the cost of the vaccine. The HPV vaccine was provided to Korean Americans and Americans by paying a fee. However, the vaccination was freely distributed in Ethiopia. The study participants may believe that free vaccines are less effective and potent. In addition, this study was in line with a qualitative study on African-American Parents, many parents were shocked at the costs of HPV, and Uninsured parents expressed caution toward HPV vaccine uptake.²⁰ Therefore, cost affects subjective norms.

Mothers who had perceived behavioral control about the HPV vaccine were about four times (AOR = 4.119; 95% CI; = 2.708–6.264), more likely to have good intentions about the HPV vaccination. This supports a study done in the United States (49.5%).²³ It may be justified that having good perceived behavioral control results in executing actions with the notion of internal and external hindrances.

Strengths and limitations of the study

The main strength of this study is that it is a community-based cross-sectional study designed with the theory of planned behavior and provides information on mothers’ intention to vaccinate their daughters aged 9–14 years old against human papillomavirus.

The limitation of this study was that the study used a cross-sectional study design, which precluded the evaluation of the temporality and causality of the observed relationships. Data were collected from participants’ self-reports; thus, these may be subjected to socially desirable responses.

Generalizability

Although this study included only Debre Tabor Town residents of mothers, the generalizability of the study results could be limited due to the relatively small number of participants. Moreover, this study’s findings may not be appropriate for the rural area population as only urban residents were enrolled.

Conclusion

Only two-thirds of mothers have the intention to vaccinate their daughters aged 9–14 years against the human papillomavirus. Attitude, perceived behavioral control, and subjective norm were predictors. This finding supports the utility of the theory of planned behavior-based framework in predicting the HPV vaccine intentions in the population. Therefore, it is better to do community mobilization toward the advantage of the HPV vaccination using social behavioral change communication strategies.

List of abbreviations

Table

AOR	Adjusted odds ratio
BDU	Bahir Dar University
CC	Cervical Cancer
CI	Confidence interval
HPV	Human Papilloma Viruses
SPSS	Social Package Science
TPB	Theory of planned behavior
YRS	Years
ACIP	Advisory committee of immunization practice
COD	Crude odds ratio

Authors’ contribution

SB selected the topic, conceived and prepared the proposal, and wrote the paper, HW performed the method part, ZAY performed data analysis, and the software and prepared the manuscript. All authors made a significant contribution to the work reported in all these areas: they took part in drafting, revising, or critically reviewing the article; gave final approval for the version to be published; and agreed on the journal to which the article was to be submitted.

Ethics approval and informed consent

The study was conducted after approval by the institutional review board of Bahir Dar University College of Medicine and Health Sciences. Then the letter was given to APHI (Amhara Public Health Institute) and Debre Tabor town administration office on October 22/2022 by Reference number 5175/1.4.4 to get permission. Written informed consent was taken.

Acknowledgments

We would like to acknowledge the study participants, data collectors, and all the team members.

Disclosure statement

No potential conflict of interest was reported by the authors.

Data availability statement

The necessary data sets used during the current study were available from the corresponding author upon reasonable request.

Supplementary material

Supplemental data for this article can be accessed on the publisher’s website at https://doi.org/10.1080/21645515.2023.2288390.

Additional information

Funding

This work was not supported by any funding.