Sociodemographic determinants of fathers´ acceptance of the human papillomavirus (HPV) vaccine of adolescent girls in Kesses (rural) and Kapseret (urban), Uasin Gishu County, Kenya

¹Department of Community Health, AMREF International University, Nairobi, Kenya

^&Corresponding author
Noelle Boreah Sutton, Department of Community Health, AMREF International University, Nairobi, Kenya

Introduction    

Non-communicable diseases (NCDs) are the leading causes of untimely deaths globally. In Africa, NCD deaths are projected to increase by 17% over the next decade, with a 27% rise in fatalities, leading to 28 million more deaths by 2030, surpassing deaths from all other causes [1]. Cervical cancer is the most prevalent malignancy in women in Eastern Africa, with 40.1 and 30.0 per 100,000 in terms of age-standardized incidence and mortality, respectively [2]. In Kenya, non-communicable diseases have become a significant public health concern, cancer being among the top on the list. In 2019, there were 3,400 deaths in Kenya, the cause being cervical cancer [1]. Cervical cancer is responsible for 13.3% of all cases of cancer and 23.2% of all cancer cases in females when disaggregated by gender [3]. Cervical cancer is mainly caused by persistent HPV infection, transmitted through sexual intercourse, with the highest rates of incidence and mortality in low- and middle-income countries. Human papillomavirus (HPV) types 16 and 18 account for 71% of all cervical cancer cases [1]. The uptake of the HPV vaccine remains low in Kenya; the coverage of the first dose in 2020 was only 33%, and for the second dose, it was only 16% [4]. The uptake is also low in Uasin Gishu County, according to Mabeya et al. [5], where out of 3083 school girls, only 39.1% received their third dose of the vaccine. In Uasin Gishu County in Western Kenya, despite prior contact with the healthcare system, women often present with late-stage cervical cancer [6]. Research done in Eldoret, Kenya, indicated that family members discuss cervical cancer vaccines and that a partner's objection significantly lowered acceptance [7]. Cervical cancer is the most common among women in Uasin Gishu County, accounting for 19.3% of all female cancer cases in the region. The age-standardized rate was 24.8 per 100,000, and 54% of the cases diagnosed were in unknown stages [8].

There is growing concern about involving men in sexual health, as they play key roles in decision-making, financial support, permission, and emotional backing in the reproductive health of their loved ones [9]. Despite progress toward gender equality, men still hold more power than women in most communities, including Kenya, where they remain key decision-makers [10]. According to De Groot et al. [11], 52.0% of adult females indicated they would require consent from their husbands before vaccinating their children. According to Adewumi et al. [12], women regarded as untraceable cited their companions as hurdles to treatment more frequently. Men positively influence women's health-seeking behaviour through decision-making, financial support, and, when needed, granting permission [13]. Owing to a scarcity of awareness and information and the assumption that men would receive less benefit from the vaccine, the vaccine's acceptance among the male population was reduced [14]. According to Brewer et al. [15], previous knowledge of human papillomavirus potentially predicts vaccine acceptance.

Human papillomavirus (HPV) is a non-enveloped, double-stranded DNA virus that causes lesions and cancers, primarily on mucosal and cutaneous surfaces [16]. Twelve high-risk HPV types are oncogenic and can cause cancer, with type 68 considered likely to be cancer-causing [17]. Human papillomavirus (HPV) is mainly transmitted through sexual intercourse, often without symptoms. It usually resolves within two years, but those with weak immune systems are at higher risk. Prevention includes vaccination, cervical cancer screening, condom use, and having one sexual partner [18].

According to Grandahl et al. [19], parents with more awareness of HPV perceived a higher vulnerability to developing human papillomavirus, it being more severe, and more benefits from the vaccine's preventative impact against cancer of the cervix [20] reported that the parents' willingness to get their girls vaccinated with the HPV vaccination was strongly influenced by characteristics like a thorough understanding of infection by the virus and vaccines against HPV, positive attitudes, media exposure, and perceived behavioural control regarding the vaccine. In the findings of Grandahl et al. [21], participants who said religion was essential had more understanding of HPV and cancer of the cervix than those who said religion played an insignificant role. According to a study conducted in Sweden by Grandahl et al. [19], religion has little effect on vaccine attitudes. In contrast, Shelton et al. [22] indicated that parents who attended religious gatherings had less favourable opinions and poorer vaccine acceptability than non-religious parents. This is concurrent with the findings of Ergül et al. [23], which found that religion negatively impacted men´s support for vaccination against HPV (P=0.001). Vermandere et al. [7] suggested that Muslims had less vaccine approval; the study also found that Catholics had greater vaccination rates than Protestants. Religious groups such as Legio Maria and Roho are anti-conventional medicine, including vaccination, and their beliefs harm vaccination uptake [24].

According to Lopez et al. [14], the vaccine's acceptance was affected by the child's gender and age. The same study also found that parents of children had higher rates of vaccine acceptance. Larebo et al. [25] indicated that when compared to parents with more than one daughter, those with only one daughter were 2.122 times more inclined to approve of HPV vaccination for their daughters. According to Lopez et al. [14], there is an association between parental gender and vaccine approval and virus awareness, with mothers showing a stronger correlation than fathers. In Poland, Smolarczyk et al. [26] found that parental knowledge and level of education are the main factors that affect their attitudes towards vaccinating their children.

According to the findings of Chigozie et al. [27], married men aged 46-55 years from rural areas believed that family members should be vaccinated and screened for cervical cancer. Men with a higher marriage age (p=0.002) and a higher education level of high school (p=0.008) and university (p=0.021) had increased vaccination support rates by an average of 3.5 times, according to Ergül et al. [23]. Kolek et al. [28] discovered a meaningful negative relationship between parental educational attainment and vaccination willingness after adjusting for beliefs and knowledge. A negative relationship existed between elder parents' readiness to consent to their children receiving the vaccine. According to Juntasopeepun et al. [29], Thai parents' acceptance of the HPV vaccine was influenced by the perceived benefits of vaccination and the belief in vulnerability to HPV and cervical cancer. Higher-income parents were more likely to agree to vaccinating children than low-income parents. Ergül et al. [23] also found that higher monthly income (p=0.028) among men had a positive association with HPV vaccine acceptance compared to minimum wage (p=0.002). Safety issues regarding the vaccine, adverse reactions, fear of encouraging dangerous sexual behaviour in their children, and availability of vaccination clinics were other barriers highlighted in the study by Juntasopeepun et al. [29].

A study in Ghana found that gender and perceived HPV beliefs are major predictors of vaccine uptake among adolescent girls [30]. Wigle et al. [31] indicated that sociocultural issues, education limits, and health system factors were significant hindrances to vaccination in low- and middle-income countries. Vermandere et al. [7] safety concerns (76%) and lack of information were key barriers to parental vaccine acceptance, with perceptions of daughters being too young also reducing acceptance. Karanja-Chege et al. [4] notes that dissenting opinions and negative comments from prominent leaders and the Catholic church increased the division and confusion of the public concerning HPV vaccines.

The health belief model suggests that health behaviours are influenced by perceptions of severity, susceptibility, and prevention benefits. In this study, factors like age, religion, occupation, marital status, and number of children impact fathers' HPV vaccine acceptance by shaping health perceptions and decision-making involvement.

This study aimed to determine the level of HPV vaccine acceptance among fathers of adolescent daughters in Uasin Gishu County, Kenya, and to assess whether socio-demographic characteristics influence their acceptance. Despite the critical role fathers play as decision-makers in the household, few studies have focused on their acceptance of the HPV vaccine for their daughters. This study addressed this gap by identifying the socio-demographic factors influencing HPV vaccine acceptance among fathers and provided valuable insights that can inform targeted vaccination messaging and campaigns aimed at fathers, ultimately supporting well-informed decision-making.

Methods     

Study design and period: community-based cross-sectional survey and qualitative interviews were done in Kesses and Kapseret sub-counties in Uasin Gishu county, Kenya, among fathers with adolescent daughters aged 10 to 19 years from January 2024 to February 2024.

Sample size determination: the sample size was determined using the Cochran formula at a 95% confidence interval and using an HPV vaccine acceptance rate of 50%:

Where n₀ = the required sample size, Z = the critical value1.96 associated with a 95% confidence interval, p = the estimated population proportion which has the attribute in question (0.5), q = 1-p, e = degrees of precision 0.05 chosen, thus = 1.96² (0.5(1-0.5))/0.05²= 385. A total of 408 fathers were recruited, adjusting the calculated sample size of 385 to account for a 6% non-response rate. This ensured statistical power and representativeness. Proportional sampling was used to determine the number of fathers to be interviewed in each sub-county. Thus, Kesses: 74,301/173,951*408 = 177 and Kapseret: 99,650/173,951*408 = 231. A few fathers, 33 (8.1%), were excluded as they did not know their daughter´s vaccination status. A total of 375 responses were included in the study (222 Kapseret, 153 Kesses).

Sampling strategy: a multi-stage sampling was adopted to choose the study location and respondents. Uasin Gishu County was chosen purposively based on the findings of previous studies conducted in the county [5,7] that showed low vaccine uptake (39.1%), which was significantly attributed to male (fathers and male guardians) objections (p-value 0.04). Kapseret sub-county, with an urban population, and Kesses sub-county, with a rural population, were purposively selected for their diverse economic status and ethnic groups. Proportional sampling determined the number of fathers to be interviewed in each sub-county.

Rural and urban households were purposively selected to find fathers with daughters aged 10-19. The researcher, with a community health promoter, identified eligible households and interviewed one father per household. Eight key informants were selected purposively, and nine fathers were randomly chosen for in-depth interviews using computer-generated sampling from the initial survey.

Study variables: the study aimed to assess fathers' acceptance of the HPV vaccine for their adolescent daughters and the socio-demographic factors influencing this. The dependent variable was vaccine acceptance, while the independent variables included fathers' age, education, marital status, religion, occupation, location, number of children, and number of adolescent daughters.

Data collection: data was collected using interviewer-administered questionnaires, key informant interviews, and in-depth interviews. Three research assistants were trained by the lead investigator on study tools, ethics, and administering questions to prevent bias. Participants were given an information sheet, and those who agreed signed a consent form before the interview.

Data analysis: the collected data was cleaned for errors, coded, and entered into SPSS version 27. Frequencies and percentages analyzed socio-demographic characteristics, while Chi-square and Fischer´s Exact tests identified factors linked to the dependent variable. Binary logistic regression assessed associations between variables, with significance defined as p-values < 0.05 at a 95% confidence interval. Key informants and in-depth interviews were recorded, transcribed non-verbally into Word documents, and analyzed. Codes were merged into sub-themes, then themes, which were verified and reported in the study findings.

Ethical consideration: the study was approved by the AMREF Ethical and Scientific Review Committee (ESRC) (ref P1554-2023). The research proposal was also approved by NACOSTI and the Uasin Gishu County administration. Participants were informed that participation was voluntary and provided written informed consent. Questionnaires were assigned unique codes to ensure anonymity and confidentiality, with no names recorded.

Results     

A total, of 375 (91.9%) fathers were enrolled in the final analysis (Table 1), with 222 (54.4%) fathers from the Kapseret sub-county (urban) and 153 (37.5%) fathers from the Kesses sub-county (rural). Most respondents were Christians (96.5%); their mean age in years was 45.5, with a standard deviation of 8.61; the median age was 44 years, and the modal age was 40 years. Most respondents reached a secondary level of education and above (53.6%) and were married (97.6%). Most respondents were employed or self-employed (89.6%) and had fewer than five children, 63.7%. Most respondents (72.3%) had one daughter aged between 10 and 19.

Out of the 375 fathers surveyed, 237 fathers (63.2%) reported that their daughters were not vaccinated, while 138 fathers (36.8%) reported that their daughters were vaccinated. In Kesses (rural), 42.8% (P=<0.001) of fathers, and in Kapseret (urban), 57.2% (P=<0.001) of fathers reported that their daughters had been vaccinated (Figure 1). Most respondents (71.7%) whose daughters were vaccinated indicated that schools and the government recommended the vaccine. Further, 66.7% of the respondents whose daughters were not vaccinated said they had inadequate information to decide (Table 2).

The research's qualitative methods generated additional reasons for acceptance or non-acceptance. For example, one participant (P2-Kesses) observed that cultural practices further complicate matters by stating that “men are culturally not supposed to accompany wives and mothers to the clinics where HPV health promotion talks take place”. A community health promoter also highlighted the challenges certain religious groups face opposing vaccination due to misinformation. She stated: “some religious people have not understood the importance of this vaccine, but if they are explained too well until they understand, they can change”.

The majority of the respondents whose daughters were not vaccinated and vaccinated had attained a secondary level of education and above. The Chi-square test had a value of 2.280 with 1 degree of freedom and a p-value of 0.131 (Table 3). The result suggests no significant association exists between fathers' educational levels and their daughters' HPV vaccination status, as the p-value is >0.05. From the qualitative data, education levels often correlate with awareness and understanding of preventive healthcare measures, with more educated fathers being more likely to accept vaccination. A community health promoter stated: “illiteracy is bad; illiteracy makes someone not understand”.

Most Christian respondents had the highest number of vaccinated and non-vaccinated daughters, n=134 and n=228, respectively. Fischer´s exact test gave a p-value of 0.135. The result suggests there is no significant association between fathers' religion and their daughters' HPV vaccination status, as the p-value is >0.05. Most of the married respondents had the highest number of non-vaccinated and vaccinated daughters, respectively, n=229 and n=137. The Fischer´s Exact test showed no significant association (p=0.163) between the father´s marital status and acceptance of vaccination for their daughters.

Most of the respondents who were employed/self-employed had the highest number of vaccinated and non-vaccinated daughters, n=131 and n=205, respectively. The Chi-square test showed a significant association (p=0.010) between fathers´ employment status and acceptance of vaccination for their daughters. Most respondents aged between 36 and 45 had the highest number of vaccinated and non-vaccinated daughters, n=70 and n=108, respectively. The Chi-square test showed no significant association (p=0.888) between the father´s age and acceptance of vaccination for their daughters.

Most respondents with below five children had the highest number of vaccinated and non-vaccinated daughters, n=90 and n=149, respectively. The Chi-square test showed that there is no significant association (p=0.648) between a father´s number of children and acceptance of HPV vaccination for their daughters. The majority of the respondents (65.7%) who had not had their daughters vaccinated had only one daughter. The Chi-square test also found no significant association (p=0.108) between the number of daughters and fathers´ acceptance of HPV vaccines for their daughters.

The majority of the respondents (n=163) from the Kapseret sub-county had the highest number of daughters who were not vaccinated. In contrast, most of the respondents (n=79) from the Kesses sub-county had the highest number of vaccinated daughters. The Chi-square test showed a significant association (p=<0.001) between a father´s geographical location and acceptance of HPV vaccination for their daughters. Employment (p=0.041) (OR=2.525, 95%CI: 1.038,6.1472) was associated with higher odds of HPV vaccine acceptance compared to being unemployed and geographical location (p=0.000) (AOR:0.359, 95%CI: 0.230,0.562) (Table 4). Living in the Kapseret sub-county (urban) was associated with lower odds of HPV vaccine acceptance compared to the Kesses sub-county (rural).

Discussion     

This study is the first to examine factors influencing fathers' acceptance of the HPV vaccine for their adolescent daughters in Uasin Gishu County. It found that 63.2% of fathers had not vaccinated their daughters, 36.8% had, and 8.1% were unsure of their daughters' vaccination status. In contrast, in a study done in Turkey, 76.7% of parents with daughters had agreed to have their daughters vaccinated against HPV [32]. This is because HPV vaccination campaigns are more advanced and widespread in developed countries such as Turkey than in developing countries such as Kenya, where resources limit campaign activities, hindering widespread awareness of the vaccine benefits. Among fathers whose daughters were not vaccinated, 60.3% were willing to vaccinate them, while 39.7% were not, mainly due to insufficient information. This finding is similar to a study done by Aragaw et al. [20] in Ethiopia, where 79.1% of the fathers were willing to have their daughters vaccinated, and 20.9% were unwilling to have their daughters vaccinated. This is also similar to the studies done by Kolek et al. [28] and Kornfeld et al. [33], where 85% and 78.8% of the male participants were ready to agree/consented to the HPV vaccination of their daughters. This high willingness may stem from fathers viewing themselves as key decision-makers and protectors of their children´s health.

This study found no significant association (p=0.131) between fathers´ level of education and their daughters' HPV vaccination status. This finding concurs with a study by Kolek et al. [28], which discovered a meaningful negative relationship between parental educational attainment and vaccination willingness. This study's findings also agree with the conclusions from Anyaka et al. [34], where there were no statistically significant associations between parental level of education (P=0.056) and HPV vaccine acceptance among parents. However, this is in contrast with a study done by Ergül et al. [23], where men with higher levels of education in high school (p=0.008) and university (p=0.021) had increased vaccination support rates by 3.5 times, and also a study was done by Akinleye et al. [35] where willingness was significantly associated with the level of education (p=0.047). The lack of a significant association between education and HPV vaccine acceptance may be due to cultural beliefs, misinformation, and logistical barriers.

The study found no significant association (p=0.135) between religion and fathers´ acceptance of the HPV vaccine for their daughters. This concurs with a study done in Sweden, where religion had little effect on vaccine attitudes [19]. This also agrees with a study in Nigeria by Anyaka et al. [34], where there was no statistical significance between the religion of parents (P=0.324) and acceptance of the HPV vaccine for their children. The qualitative aspect found much opposition from catholic church members compared to other denominations. This concurs with studies done by Shelton et al. [22], which indicated that parents who went to religious gatherings had less favourable opinions and poorer vaccine acceptability than non-religious parents, and also a study done by Ergül et al. [23], which found that religion negatively impacted men´s support for vaccination against HPV. This finding is, however, in contrast with a study was done by Vermandere et al. [7], which suggested that Catholics had higher vaccination rates than protestants. The lack of association could be that religious beliefs may influence some individuals, but factors like perceived HPV risk, trust in healthcare, and vaccine access often play a larger role in vaccine acceptance.

This study found a significant association (p<0.001) between the geographical location of respondents and HPV vaccine acceptance for their daughters. Being from the Kapseret sub-county decreased the odds of fathers' HPV vaccine acceptance for their adolescent daughters (AOR 0.368: 95% CI, 0.220-0.613). Participants from the Kesses sub-county (rural) were more likely to have their daughters vaccinated than those from the Kapseret sub-county (urban). These findings concurred with the findings of Chigozie et al. [27] that men from rural areas believed that family members should be vaccinated and screened for cervical cancer. The findings also concur with a study done by Degarege et al. [36] in India, where acceptance of HPV vaccination for daughters was high among rural parents. HPV vaccine acceptance may be higher in rural areas due to trust in local healthcare, effective public health initiatives, limited misinformation, and community support for cancer prevention over sexual health.

The majority of the respondents' age in this study were below 45 years old (n=192, 51.2%). This concurs with a study by Anyaka et al. [34], where most respondents were 36-45 years old (n=208, 40.7%). The study found no significant association between the age of the respondents and their daughters' HPV vaccination status (p=0.480). This finding is in contrast with a study done by Chigozie et al. [27], where men aged 46-55 years from rural areas believed that family members should be vaccinated and screened for cervical cancer. The lack of association between age and HPV vaccine acceptance may stem from universal health messaging, consistent decision-making, and factors like perceived risk and trust in vaccines, with broad age groupings potentially masking subtle differences.

The study found no association (p=0.163) between marital status and respondents' daughters' HPV vaccination status. This is in contrast with the finding of the study by Chigozie et al. [27] in Nigeria, which found that married men were in favour of their family members being vaccinated and screened for cervical cancer. Human papillomavirus (HPV) vaccine acceptance is likely unaffected by marital status, as health awareness, perceived risk, and cancer prevention messaging are more influential. The majority of the respondents in the study were business people or self-employed (n=314, 83.7%). These findings are similar to those of Anyaka et al. [34], where most respondents were traders/businesspeople (n=296, 57.9%). The study found a significant association (p=0.024) between employment status and HPV vaccine acceptance. Fathers' employment status may influence HPV vaccine acceptance due to better financial resources, healthcare access, health awareness, and focus on family well-being.

This study found no association between the respondent's number of daughters and HPV vaccine acceptance. Most respondents who had not vaccinated their daughter had only one daughter. In contrast, a study by Larebo et al. [25] indicated that compared to parents with more than one daughter, those with only one daughter were 2.122 times more inclined to approve HPV vaccination for their daughters. The number of daughters a father has likely doesn't affect HPV vaccine acceptance, as it is influenced more by awareness, perceived risk, and public health recommendations than family size.

The study found that parents with both male and female children had the highest vaccination and non-vaccination rates, with no association between child gender and HPV vaccine acceptance for daughters. However, a study by Lopez et al. [14] found that the vaccine's acceptance was affected by the child's gender. Fathers with both male and female children may have higher vaccine acceptance and refusal rates due to increased awareness, mixed opinions, and a protective attitude towards their children.

This study's limitations prevent generalizing findings to Uasin Gishu County or Kenya. The cross-sectional design limits causal conclusions and tracking of attitude changes. Additional limitations include recall bias from self-reported vaccination status and potential confounding factors like vaccination campaigns and health system influences.

We recommend further studies to investigate the observed disparity between fathers' high awareness of the HPV vaccine and their daughters' low acceptance of the vaccine. A longitudinal cohort study would provide more information about the elements that influence vaccine acceptability over time. To improve HPV vaccine uptake, efforts should educate fathers on HPV and vaccination benefits, address cultural norms and misinformation, expand access in underserved areas, and engage fathers through tailored messaging and policy inclusion.

Conclusion     

Our study found low HPV vaccination rates among daughters, reflecting limited paternal acceptance influenced by socio-demographic factors like employment and location. However, low uptake also stems from barriers such as lack of awareness, cultural norms, misinformation, logistical challenges, and external influences like school or government initiatives bypassing paternal consent. Addressing these barriers is crucial to improving fathers' acceptance and vaccine uptake.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Noelle Sutton, principal investigator, conceptualized, designed, and executed the study, methodology, and data analysis, drafted the initial manuscript and revised it; Josephat Nyagero and Joachim Osur aided in the conceptualization and design of the study, methodology, review, and editing of the manuscript. All the authors read and approved the final version of this manuscript.

Acknowledgments     

The authors would like to acknowledge the County Health Department of Uasin Gishu for their support in implementing the study.

Tables and figure     

Table 1: sociodemographic characteristics of fathers

Table 2: reasons for vaccination/non-vaccination

Table 3: sociodemographic characteristics vs HPV vaccine acceptance

Table 4: predictors of HPV vaccine acceptance

Figure 1: human papillomavirus (HPV) vaccination status of adolescent girls by sub-county

References