Knowledge, attitudes, and factors associated with documented human papillomavirus vaccination among girls aged 9-14 years in Doufelgou Health Zone, Togo, December 2023-January 2024: a cross-sectional study

¹Department of Public Health, Bircham International University, Madrid, Spain, ²Research and Planning Department, Ministry of Health and Public Hygiene, Lome, Togo, ³Interdisciplinary Research Laboratory in Social and Health Sciences, Joseph Ki-Zerbo University, Ouagadougou, Burkina Faso, ⁴National Programme for the Control of HIV/AIDS, Sexually Transmitted Infections and Viral Hepatitis, Ministry of Health and Public Hygiene, Lome, Togo, ⁵Faculty of Medicine and Allied Health Professions, Universite Clermont Auvergne, Clermont-Ferrand, France

^&Corresponding author
Wankpaouyare Gmakouba, Department of Public Health, Bircham International University, Madrid, Spain

Introduction    

Cervical cancer remains a major public health problem. In 2022, approximately 660,000 new cases and 350,000 deaths occurred worldwide, with the greatest burden in low- and middle-income countries. Persistent infection with oncogenic human papillomavirus (HPV) types is the principal cause of cervical cancer [1]. The disease is largely preventable through vaccination before exposure to HPV, screening, and timely treatment of precancerous lesions. The World Health Organization (WHO) elimination strategy sets the 2030 targets of vaccinating 90% of girls before 15 years of age, screening 70% of women at ages 35 and 45 years, and treating 90% of women with precancerous lesions or invasive cancer [2].

Reaching the vaccination target depends on more than vaccine availability. Family trust, the quality of counselling, community mobilization, and the capacity to reach both school-going and out-of-school girls influence uptake. Programmes in low- and middle-income countries have generally achieved higher coverage when school-based delivery is combined with health-facility sessions and community outreach [3,4]. Parents' and guardians' knowledge and attitudes are therefore important for understanding the transition from awareness and acceptance to actual vaccination.

Togo conducted a nationwide catch-up campaign from 27^th November, to 1^st December, 2023, targeting approximately 656,240 girls aged 9-14 years, and introduced HPV vaccination into routine immunization on 4^th December, 2023 [5]. The campaign was a multi-age catch-up activity for girls aged 9-14 years, whereas girls aged 9 years constituted the annual entry cohort for routine HPV vaccination [5,6]. WHO evidence supports a one-dose or two-dose schedule for immunocompetent girls aged 9-14 years, while immunocompromised individuals should receive at least two doses and, where feasible, three doses [7,8]. Under the single-dose schedule adopted in Togo, one documented dose constituted complete HPV vaccination for immunocompetent girls aged 9-14 years [6,8].

The national burden remains substantial. GLOBOCAN 2024 estimates rank cervical cancer as the second most frequently diagnosed cancer among women in Togo, with an estimated 746 new cases and 452 deaths in 2024 [9]. Doufelgou Health Zone, in the Kara Region of Northern Togo, had an estimated population of 84,767 in 2023. Health zone programme documents recorded 6,576 vaccinated girls among 8,200 girls aged 9-14 years, corresponding to administrative coverage of 80.2% [6]. By age group, 1,342 of 1,401 girls aged 9 years (95.8%) and 5,234 of 6,799 girls aged 10-14 years (77.0%) were vaccinated during the campaign [6]. A local organising committee (Comite local d'organisation, CLO), chaired by the Prefect of Doufelgou, coordinated sensitisation activities to promote parental acceptance of vaccination [6]. Routine HPV delivery began on 4^th December, 2023 and study data collection ended in January 2024; therefore, no longitudinal trend in routine HPV coverage could yet be assessed. The study did not collect a time series of other routine-immunization tracer indicators in Doufelgou.

International evidence shows that HPV vaccine coverage remains uneven, particularly in low- and middle-income countries [10,11]. Studies in Kenya, Tanzania, Nigeria, Senegal, and Ethiopia have linked uptake or acceptance to parental knowledge, concerns about adverse effects and fertility, school attendance, counselling, satisfaction with services, and the accessibility of vaccination sessions [12-17]. However, evidence was limited on how these factors operated immediately after national HPV vaccine introduction in Togo.

The 2023 introduction occurred amid rumours about fertility and vaccine safety. Health authorities and partners responded through community dialogue, parent associations, women's groups, and engagement of administrative, traditional, and religious leaders [18].

This study therefore aimed to describe mothers' and guardians' characteristics, knowledge, attitudes, and information sources and to identify factors associated with documented HPV vaccination among girls aged 9-14 years in Doufelgou Health Zone.

Methods     

Study design and setting: a descriptive and analytical cross-sectional study was conducted from December 2023 to January 2024 in Doufelgou Health Zone, Kara Region, Northern Togo. The source population comprised mothers or female guardians of girls aged 9-14 years residing in the health zone. The analysis included 369 participants with usable information on sociodemographic characteristics, knowledge, attitudes, information sources, and vaccination status verified from the selected girl's vaccination card.

Participants and eligibility: women were eligible if they had lived in Doufelgou Health Zone since the start of the HPV vaccination campaign, were the mother or guardian of at least one girl aged 9-14 years, and provided informed consent. Women who declined participation, had no girl in the target age group, or provided a questionnaire with insufficient information for analysis were excluded. When a household included more than one eligible girl, one girl was selected by simple random sampling.

Sample size and sampling: the minimum sample size was calculated using the Schwartz formula with a 95% confidence level, 5% precision, and an expected proportion of 50% because no robust local estimate was available. After finite-population correction for 8,200 eligible girls, the minimum sample was 367; 369 mothers or guardians were ultimately included. A three-stage community sampling procedure adapted from Diongue et al. [16] was used. First, health areas were selected with probability proportional to the estimated number of eligible girls. Second, villages or neighbourhoods were selected by simple random sampling within selected health areas. Third, households were identified through a random-walk procedure starting from the centre of each selected locality, with the initial direction determined by tossing a pen.

Data collection and quality assurance: ten female interviewers received one day of training on the study objectives, questionnaire content, interviewing techniques, confidentiality, and vaccination-card verification. Data were collected through face-to-face interviews using a structured questionnaire. The tool was pretested among 12 mothers of girls aged 9-14 years in an area not selected for the main survey; wording, comprehension, and question order were revised accordingly. Vaccination status was verified directly from the girl's vaccination card.

Variables and operational definitions: the outcome was documented HPV vaccination, coded as yes or no. A girl was classified as vaccinated when one HPV vaccine dose was recorded on her vaccination card, consistent with the single-dose schedule used in Togo for immunocompetent girls aged 9-14 years; one documented dose therefore represented complete vaccination [6,8]. Explanatory variables included the respondent's age, education, occupation, and marital status; the girl's school attendance; awareness of cervical cancer and HPV vaccination; knowledge of cervical cancer risk factors and prevention methods; knowledge of the vaccine target population and schedule; principal sources of information; and attitudes towards vaccination in general and HPV vaccination specifically. Table 1 summarises the study variables and the analytical categories used, making the operational definitions transparent and easier to interpret.

Statistical analysis: data were entered and processed in Microsoft Excel and analysed in SPSS (2021 release). Categorical variables were summarized as frequencies and percentages. Associations between documented vaccination and explanatory variables were examined using Pearson's Chi-square test or Fisher's exact test when expected cell counts were small. Crude odds ratios (cORs) and 95% confidence intervals (CIs) were calculated; the Haldane-Anscombe correction was applied when a contingency-table cell contained zero observations. Because only 46 girls were classified as unvaccinated, an exploratory and parsimonious multivariable logistic regression model was fitted, grouping categories where necessary. Variables showing complete or quasi-complete separation were excluded from the standard model. Adjusted odds ratios (aORs) with 95% CIs are reported. Statistical significance was set at 5%. Because documented vaccination was common, odds ratios may overstate associations relative to prevalence ratios.

Ethical approval and consent to participate: this observational study, based on individual interviews and the verification of vaccination cards, involved no experimental intervention, biological specimen collection, or invasive procedure. The research team therefore considered the study to pose minimal risk to participants. Formal approval from an ethics committee was not sought before the study was conducted. Nevertheless, ethical principles related to respect for persons, voluntary participation, confidentiality, and data protection were strictly observed. Before each interview, the study objectives, data collection procedures, expected benefits, possible inconveniences, confidentiality safeguards, and the voluntary nature of participation were clearly explained to each mother or guardian. The information was provided in a local language whenever necessary. Written, free, and informed consent was obtained from each participant before the interview and the review of the vaccination card of the girl concerned. Participants were free to decline participation or withdraw from the study at any time, without providing a reason and without any adverse consequences. The questionnaires contained no names or other personal identifiers. The data collected were stored, processed, and analysed anonymously and confidentially and were used exclusively for the purposes of this research.

Results     

Documented HPV vaccination at the post-campaign survey: at the post-campaign household survey, 323 of the 369 selected girls had one HPV vaccine dose documented on their vaccination card, corresponding to 87.5% (Wilson 95% CI: 83.8-90.5); 46 girls (12.5%) had no documented dose. Table 2 presents the card-documented vaccination status.

Participant characteristics: participants were predominantly aged 30-39 years (210; 56.9%). More than half had no formal education (208; 56.4%), 193 (52.3%) were agricultural producers, and 296 (80.2%) were married. All selected girls were aged 9-14 years by eligibility; 221 (59.9%) were attending school and 148 (40.1%) were not attending school. Table 3 presents the complete sociodemographic profile of the mothers or guardians and the school-attendance status of the selected girls.

Knowledge and attitudes: among respondents, 71.3% had heard of cervical cancer, 72.6% knew at least one risk factor, and 62.1% could identify at least one prevention method. Awareness of the HPV vaccine was nearly universal (98.9%), although knowledge of the target population (68.8%) and the vaccination schedule (65.0%) was less complete. A favourable attitude towards HPV vaccination was reported by 87.0% of participants. These knowledge and attitude indicators are presented in detail in Table 4.

Sources of information: health centres were the main source of information on cervical cancer, reported by 74.0% of participants. By contrast, traditional town criers were the leading source of information on the HPV vaccination campaign (66.7%), followed by radio or television (23.0%). Table 5 shows the distribution of the principal information sources reported for cervical cancer and HPV vaccination.

Factors associated with documented HPV vaccination: in bivariate analysis, documented HPV vaccination was associated with the respondent's age, education, occupation, the girl's school-attendance status, awareness of cervical cancer, knowledge of at least one prevention method, knowledge of the vaccine target population and schedule, and attitude towards HPV vaccination. Table 6 presents the distribution of vaccinated and unvaccinated girls, p-values, and crude odds ratios. The multivariable model was statistically significant (likelihood-ratio p<0.001; McFadden pseudo-R-squared=0.404). After adjustment, respondents aged 40 years or older had markedly lower odds of having a girl with documented vaccination than respondents younger than 40 years (aOR=0.05; 95% CI: 0.02-0.12). Similarly, respondents who knew no cervical cancer prevention method had lower odds of documented vaccination than those who knew at least one method (aOR=0.21; 95% CI: 0.09-0.51). The adjusted estimates for all variables retained in the final exploratory model are shown in Table 7.

Discussion     

Principal findings: at the post-campaign survey, 323 of 369 selected girls (87.5%) had a single HPV vaccine dose documented on their vaccination card. Vaccine awareness was high, although knowledge of the target population, schedule, and cervical cancer prevention remained incomplete. Separate administrative programme records showed that 1,342 of 1,401 girls aged 9 years (95.8%) and 5,234 of 6,799 girls aged 10-14 years (77.0%) were vaccinated, for an overall campaign total of 6,576 of 8,200 girls (80.2%). These administrative estimates provide programme context but are not directly comparable with the survey proportion because the denominators and measurement methods differ. Traditional town criers were the most frequently reported campaign information source. Older respondent age and absence of knowledge about cervical cancer prevention remained associated with lower odds of documented vaccination after adjustment.

Coverage and programme implications: the difference between 9-year-old girls and older catch-up cohorts is consistent with operational challenges during multi-age campaigns. Older girls may be more mobile, absent from school, or difficult to identify outside formal education. Evidence from low- and middle-income countries indicates that school-based delivery performs best when complemented by health-facility sessions, community outreach, and active follow-up of missed girls [3,4]. Doufelgou should therefore consolidate routine vaccination at the entry age while conducting targeted catch-up for girls aged 10-14 years who were missed during the campaign. The local organising committee chaired by the Prefect of Doufelgou coordinated parental sensitisation during the campaign; sustaining this multisectoral coordination mechanism could support routine vaccination and targeted catch-up.

Knowledge and communication channels: almost all respondents had heard of the HPV vaccine, exceeding the 81.6% awareness reported among mothers or guardians in Diakhao Health Zone, Senegal [16]. Awareness, however, did not always reflect detailed understanding: approximately one-third of respondents did not know the target population or schedule. Communication should therefore move beyond campaign announcements and explain the causal pathway from persistent HPV infection to cervical cancer, the purpose and eligibility criteria for vaccination, the single-dose schedule, expected adverse events, and where missed girls can be vaccinated.

The information sources differed by topic. Health centres were the principal source of cervical cancer information (74.0%), consistent with their continuing role in routine health education, whereas traditional town criers were the principal source of HPV campaign information (66.7%), reflecting time-limited community mobilisation. Sustainable routine delivery should therefore combine continuous counselling in health facilities with periodic school and community outreach. The prominent role of traditional town criers is a context-specific programme asset. Their reach confirms the value of trusted local communication channels in rural settings. Town criers can announce sessions and encourage participation, while trained health workers address clinical questions about safety, fertility, adverse events, and cancer prevention. A coordinated network involving town criers, community health workers, schools, local radio, women's groups, and health facilities is likely to be more effective than reliance on a single channel.

Factors associated with documented vaccination: knowledge of at least one cervical cancer prevention method was positively associated with documented vaccination, consistent with evidence from Kenya, Nigeria, and Ethiopia linking knowledge of cervical cancer or HPV vaccination to acceptance and uptake [12,14,17]. The strong association with respondent age deserves additional investigation. Lower documented vaccination among respondents aged 40 years or older may reflect differences in exposure to campaign messages, familiarity with communication channels, confidence in a recently introduced vaccine, or household decision-making. Qualitative research could clarify these mechanisms and inform age-sensitive counselling.

Interpretation of counterintuitive findings: some bivariate findings should not be translated directly into programme recommendations. Higher documented vaccination among girls not attending school may indicate effective community outreach to out-of-school girls, but it may also reflect selection bias or residual confounding. Similarly, apparently higher vaccination among respondents who did not know the target population or schedule may result from reversed coding, sparse cells, or post-campaign measurement. Before final analytic publication, the variable dictionary, coding, vaccination cards, and source registers should be rechecked. The survey proportion of 87.5% must also remain distinct from administrative coverage because the denominators and measurement procedures differ.

Strengths: the study combined household survey data with the health zone administrative information and verified vaccination status from cards, reducing reliance on recall. It also documented locally important communication channels that are not routinely captured in vaccination reports. The findings therefore provide practical information for post-campaign catch-up and routine service improvement in Doufelgou.

Limitations: the cross-sectional design does not establish temporality or causality between respondents' characteristics and girls' vaccination. Data collection occurred immediately after the catch-up campaign, so awareness and uptake may reflect unusually intensive mobilization rather than routine programme performance. Incomplete or inaccurately completed cards could have caused misclassification. Important factors such as distance to vaccination sites, household income, vaccine availability, exposure to specific rumours, trust in health services, and decision-making autonomy were not sufficiently measured. The multivariable analysis was exploratory because only 46 girls were unvaccinated, some cells were sparse, and several variables showed complete or quasi-complete separation. The analysis did not fully account for clustering from the multistage sampling design, potential interactions, or unmeasured confounding. Because the study was conducted in one health zone, its findings should not be generalized automatically to all of Togo. Because routine HPV vaccination had only just begun and other tracer indicators were not collected, the study could not assess changes over time in HPV coverage or in other routine-immunization indicators in Doufelgou.

Conclusion     

Among the 369 selected girls aged 9-14 years, 323 (87.5%) had one HPV vaccine dose documented on their vaccination card. Mothers and guardians showed high awareness of the vaccine, but knowledge of its target population, schedule, and cervical cancer prevention remained incomplete. Health centres were the main source of cervical cancer information, whereas traditional town criers were the main source of campaign information. After adjustment, respondent age of 40 years or older and lack of knowledge of a cervical cancer prevention method were associated with lower odds of documented vaccination. These findings support targeted counselling for older mothers and guardians, clearer communication on cervical cancer prevention and the single-dose schedule, and catch-up of girls without documented vaccination through coordinated health-facility, school, radio, and community strategies.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Wankpaouyare Gmakouba: conceptualization, data curation, formal analysis, investigation, methodology, project administration, resources, software, supervision, validation, visualization, drafting of the original manuscript, and review and editing; Komi Ameko Azianu: conceptualization, data curation, formal analysis, methodology, validation, and review and editing; Salaraga Bantakpa: conceptualization, data curation, formal analysis, methodology, validation, and review and editing; Labaguibe Gangak: formal analysis and review and editing; Pitabinawè Deabalo: review and editing. All the authors read and approved the final version of this manuscript.

Acknowledgments     

The authors thank the participating mothers and guardians, the selected girls and their families, the data collectors, and the Doufelgou Health Zone Team for their cooperation. The authors reviewed the complete manuscript and remain fully responsible for its accuracy, originality, and integrity.

Tables     

Table 1: variables and analytical categories used to assess factors associated with card-documented human papillomavirus vaccination among girls aged 9-14 years, Doufelgou Health Zone, Togo, December 2023-January 2024 (N=369)

Table 2: card-documented human papillomavirus vaccination status among selected girls aged 9-14 years, Doufelgou Health Zone, Togo, December 2023-January 2024 (N=369)

Table 3: sociodemographic characteristics of participating mothers or guardians and school attendance of selected girls aged 9-14 years, Doufelgou Health Zone, Togo, December 2023-January 2024 (N=369)

Table 4: knowledge and attitudes related to cervical cancer and human papillomavirus vaccination among mothers or guardians of girls aged 9-14 years, Doufelgou Health Zone, Togo, December 2023-January 2024 (N=369)

Table 5: principal sources of information on cervical cancer and human papillomavirus vaccination reported by mothers or guardians of girls aged 9-14 years, Doufelgou Health Zone, Togo, December 2023-January 2024 (N=369)

Table 6: factors associated with card-documented human papillomavirus vaccination in bivariate analysis among girls aged 9-14 years, Doufelgou Health Zone, Togo, December 2023-January 2024 (N=369)

Table 7: factors independently associated with card-documented human papillomavirus vaccination in exploratory multivariable logistic regression among girls aged 9-14 years, Doufelgou Health Zone, Togo, December 2023-January 2024 (N=369)

References