EVALUATION OF THE CHALLENGES TO HPV VACCINATION IN NIGERIA

CHAPTER ONE

INTRODUCTION

1.1 Background of the study

Human papillomavirus (HPV) is characterized as a disease that affects both genders equally (Bosch et al., 2015). As many as 80% of sexually active individuals will contract some form of HPV during their lifetime, rendering HPV the most prevalent sexually transmitted infection (STI) globally and the primary cause of cervical cancer, which has a significantly high mortality rate (Bosch et al., 2015; WHO, 2019). The designation of HPV as a human carcinogen was established in the late 1970s when Dr. Harold identified the causative relationship between HPV infections and cervical cancer (Nour & Nawal, 2019). Cervical cancer continues to pose a substantial global health challenge, being the second most prevalent cancer among women and the most frequent gynecological malignancy globally (Torre et al., 2017; Makwe et al., 2016).

Cervical cancer is projected to impact over 560,000 women each year, resulting in roughly 275,000 fatalities yearly, with over 55% of these cases arising in poor nations (Agida et al., 2015). Approximately 80% of sexually active females globally will have been infected with HPV by the age of 50 or at some point in their life (WHO, 2019). HPV is more common among the younger demographic, particularly among the 20 to 30-year age bracket, which encompasses a significant number of college students (Licht et al., 2020). The World Health Organization reported that around 23.7% of women in the general population of Nigeria are infected with cervical HPV at any one moment (WHO, 2019). A significant incidence of cervical cancer has been documented in Abuja, Nigeria's Federal Capital Territory (Umezulike et al., 2017). A research in Ibadan South-West Nigeria revealed an overall HPV infection prevalence of 26.3%, with a frequency of 24.8% among women devoid of cervical lesions (Thomas et al., 2014). A research conducted in Enugu, South-east Nigeria, indicated a significant incidence (78%) of cervical cancer in women under the age of 30 (Ugwu et al., 2021). University students and young adults exhibit a significant incidence of HPV infection due to their high-risk sexual activity, insufficient awareness about HPV infection and associated disorders, and misconceptions about their vulnerability (Sandfort et al., 2019). Research among university and college students globally indicates that knowledge of genital HPV infection varies between 13% and 78%, but awareness of HPV vaccinations spans from 10% to 87%. The perceived risk of students contracting genital HPV infection varies between 12.7% and 42%, whereas the chance of having cervical cancer ranges from 19.9% to 68% (Makwe et al., 2022).

Given the significant prevalence of cervical cancer, several preventive measures are advocated. Immunization against oncogenic HPV strains is a crucial measure to reduce the incidence of the illness, hence reducing the associated morbidity and death, since there is presently no treatment for HPV infection (WHO, 2019). Research in Nigeria indicates a significant acceptance of the HPV vaccination among women, with a notably high desire to obtain the vaccine among female university students (Ugwu et al., 2023; Adejuyigbe et al., 2019; Perlman et al., 2018). Adolescents and college-aged women exhibited greater vaccination acceptance and are more likely to promote it to others compared to married women and moms regarding their children (Agida et al., 2015).

Notwithstanding the worldwide advocacy for HPV vaccination as an efficacious strategy to avert HPV-related malignancies, Nigeria encounters significant obstacles in executing and attaining extensive vaccination coverage (WHO, 2020). The Nigerian healthcare system has challenges including poor infrastructure, limited public knowledge, and insufficient government financing, all of which result in low vaccination rates (Eze et al., 2019). Vaccination uptake rates are far below the World Health Organization's objectives, suggesting that considerable obstacles hinder persons from obtaining this vital preventative treatment (Ngoma et al., 2022).

The socio-cultural environment of Nigeria exacerbates the obstacles to HPV vaccination. Cultural views, social stigma, and misinformation about HPV and its vaccinations provide considerable challenges, particularly in rural regions where healthcare literacy is less and traditional beliefs are more entrenched (Obi et al., 2018). A significant number of Nigerians have misunderstandings about the HPV vaccination, linking it to promiscuity or deeming it superfluous for younger individuals who are not sexually active. This view constrains parental permission for vaccination young girls, the main focus of HPV prevention initiatives (Dempsey et al., 2015). Moreover, religious convictions in different areas of Nigeria exacerbate vaccine hesitation, as some religious leaders dissuade vaccination, linking it to overarching anti-Western emotions or health fallacies (Afolabi et al., 2020). The cultural and religious obstacles need focused, community-oriented education to mitigate opposition and enhance public awareness of HPV's health dangers and the essential importance of vaccination.

Economic limitations substantially impede HPV vaccination initiatives in Nigeria, characterized by prevalent out-of-pocket healthcare costs and restricted government support for preventative health measures (World Bank, 2019). Despite the relative affordability of HPV vaccinations in many affluent nations, they remain prohibitively expensive for the typical Nigerian, especially in low-income rural regions (Okonofua et al., 2020). This cost obstacle disproportionately impacts people with restricted healthcare access, resulting in notable variations in immunization rates across various socio-economic categories. Nigeria's reliance on donor agencies for health resources creates vulnerabilities due to potential fluctuations in financing influenced by international agendas, political dynamics, or changes in donor policies. In the absence of continuous and sustained financial backing, HPV vaccination programs may encounter disruptions, jeopardizing long-term immunization objectives (Adeoye et al., 2021). Consequently, budgetary constraints, coupled with insufficient public health financing, provide substantial obstacles to attaining extensive HPV vaccine coverage.

Logistical complications and structural inefficiencies within Nigeria's healthcare delivery system intensify the obstacles to HPV vaccination. The nation's healthcare system, especially in rural regions, often lacks adequate cold chain storage facilities to maintain vaccine effectiveness, resulting in waste and unsuccessful immunization initiatives (Bawa et al., 2020). Furthermore, insufficient training and staffing challenges result in a lack of skilled healthcare personnel to deliver vaccinations effectively, even when they are accessible (Yaya et al., 2018). Inadequate outreach services and deficient record-keeping hinder the tracking of vaccinated persons, potentially leading to insufficient vaccination coverage and redundant efforts (Olumide & Akinyemi, 2019). These logistical obstacles diminish vaccination rates and erode public confidence in health initiatives, since communities may interpret discrepancies and delays as indicators of ineptitude or disregard within the healthcare system. Confronting these logistical issues is essential for establishing a successful, sustained HPV vaccination initiative in Nigeria.

Confronting the obstacles to HPV vaccination in Nigeria is essential for decreasing the elevated incidence of HPV-related malignancies, particularly cervical cancer, and enhancing women's health outcomes. Overcoming these issues requires concerted efforts from government agencies, international organizations, community leaders, and healthcare practitioners to guarantee that immunization programs are accessible, inexpensive, and culturally acceptable (Anorlu, 2019). Community-oriented health education initiatives and collaborations with religious and traditional authorities may significantly contribute to debunking misconceptions and fostering public confidence. Moreover, investments in healthcare infrastructure and worker training are crucial to improve service delivery and guarantee the availability of HPV vaccinations to all persons in need. Assessing the current obstacles and mitigating them via comprehensive methods might foster an atmosphere conducive to the success of HPV vaccination programs, resulting in sustained enhancements in public health and a decrease in the prevalence of HPV-related illnesses in Nigeria. Thus, the need for this investigation.

1.2 Statement of the Problem

The HPV vaccination initiative in Nigeria has several challenges that impede the effective implementation and broad acceptance of preventative strategies against HPV-associated illnesses, especially cervical cancer. A major difficulty is the insufficient awareness and understanding of HPV and its vaccine, which significantly hinders vaccination rates. A significant segment of the Nigerian populace lacks awareness of HPV, its transmission, and its correlation with cervical cancer, with research demonstrating particularly low awareness levels among parents and adolescents, the primary demographic of concern (Adefolalu et al., 2019; Ezechi et al., 2020; Obiri-Yeboah et al., 2021). The public's inadequate comprehension of the vaccine's advantages, coupled with existing misunderstandings, fosters extensive hesitation. The absence of knowledge is exacerbated by cultural stigmas, since HPV is sexually transmitted, and discussions on the vaccine are often evaded or dissuaded, particularly in conservative areas (Anorlu et al., 2018; Obi et al., 2020). In the absence of focused education and public health initiatives, many individuals are improbable to participate in preventive healthcare, resulting in a heightened vulnerability to HPV infections and associated ailments.

The socio-cultural impediments to HPV vaccination in Nigeria, including religious and cultural convictions, exacerbate immunization efforts. Numerous communities possess entrenched views toward Western medicine, and the HPV vaccine is often regarded with skepticism or seen as a promotion of sexual promiscuity among adolescents (Awe et al., 2019; Okunola et al., 2021; Adejumo et al., 2019). Additionally, prominent religious and community leaders, who often act as pivotal decision-makers or influencers, sometimes resist the HPV vaccination, seeing it as misaligned with moral or cultural norms (Aniebue et al., 2020; Mohammed et al., 2019; Oye-Adeniran et al., 2020). These socio-cultural views engender opposition to HPV vaccination initiatives and foster a wider skepticism towards public health campaigns, thereby diminishing vaccination rates. Given that health education alone may insufficiently address these cultural and religious concerns, there is a need for culturally attuned tactics that include community leaders to cultivate support and confidence for the vaccination initiative.

Nigeria's healthcare system has logistical and infrastructural limitations that hinder the supply of HPV vaccines, in addition to socio-cultural obstacles. Numerous healthcare institutions, particularly in rural and disadvantaged areas, are deficient in essential resources, such as cold storage, educated staff, and dependable vaccination supply chains (Akinyemi et al., 2021; Olatunji et al., 2020; Okolo et al., 2020). These complications lead to lost immunization opportunities and difficulties in preserving the vaccine's efficacy and safety. Financial limitations intensify the predicament; although foreign assistance, the expenses related to sustaining a viable vaccination program often burden the national healthcare budget, which is already constrained (Adekunle et al., 2020; Adetunji et al., 2019; World Bank, 2020). Achieving extensive HPV vaccine coverage in Nigeria remains a formidable issue without substantial improvements in healthcare facilities and finance. Confronting these systemic challenges is crucial for surmounting the complex obstacles to HPV vaccination and alleviating the impact of HPV-related disorders. This research aims to assess the obstacles to HPV vaccination in Nigeria.

1.3 Objectives of the study

The primary objective of this study is to critically evaluate the challenges to HPV vaccination in Nigeria. Specific objectives of this study are to:

1. To assess the level of awareness and knowledge about HPV and HPV vaccination among different demographic groups in Nigeria

2. To the socio-cultural barriers influencing perceptions and acceptance of the HPV vaccine among Nigerian communities

3. To investigate the impact of logistical and infrastructural challenges on the distribution and accessibility of the HPV vaccine in rural and urban areas

4. To evaluate financial and policy-related constraints affecting the implementation and sustainability of HPV vaccination programs in Nigeria

1.4 Research Questions

The following research questions which are in line with the objectives of this study will be answered in this study:

1. 1. 1. What is the level of awareness and knowledge about HPV and HPV vaccination among different demographic groups in Nigeria?

      2. What are the socio-cultural barriers influencing perceptions and acceptance of the HPV vaccine among Nigerian communities?

      3. What is the impact of logistical and infrastructural challenges on the distribution and accessibility of the HPV vaccine in rural and urban areas?

      4. What are the financial and policy-related constraints affecting the implementation and sustainability of HPV vaccination programs in Nigeria?

1.5 Research Hypotheses

To determine the effectiveness of this study, the following research null hypotheses will be formulated to guide the study and it will be tested at 0.05% levels of significance.:

Ho: The level of awareness and knowledge about HPV and HPV vaccination among different demographic groups in Nigeria is low

Ha: The level of awareness and knowledge about HPV and HPV vaccination among different demographic groups in Nigeria is high

1.6 Significance of the study

This research carries substantial importance for a range of stakeholders, particularly those involved in public health policy, healthcare delivery, and initiatives aimed at disease prevention.

For those in positions of authority, comprehending the obstacles to HPV vaccination in Nigeria offers crucial perspectives that can inform the development of more impactful health policies and intervention strategies. In the realm of HPV prevention, the implementation of effective policies is essential for guaranteeing the availability, affordability, and accessibility of vaccines. Understanding these challenges enables decision-makers to customize health initiatives that take into account the distinct socio-cultural and economic factors influencing HPV vaccination rates. Well-informed policies can significantly contribute to the development of a stronger healthcare infrastructure, thereby facilitating extensive immunization initiatives that directly impact the decrease of HPV infections and associated cervical cancer occurrences.

The findings of this study will also be advantageous for healthcare providers, such as physicians, nurses, and educators in the healthcare field. This study seeks to uncover the deficiencies in understanding, prevalent misconceptions, and prevailing attitudes regarding HPV vaccination among patients. Healthcare professionals may utilize this information to enhance their communication with patients, tackling particular concerns, misconceptions, and beliefs that could hinder vaccination efforts. Providing healthcare providers with a comprehensive insight into these obstacles empowers them to deliver customized education and guidance to patients, thereby cultivating a more nurturing atmosphere for the acceptance of the HPV vaccine. This methodology is crucial in fostering confidence in the healthcare system and promoting the objective of enhancing HPV vaccination rates throughout Nigeria.

This study illuminates the significant influence that community leaders, religious figures, and local influencers exert in molding public perceptions and actions related to health practices, such as vaccination. The vaccination against HPV is a nuanced subject frequently shaped by various cultural, social, and religious influences. This research underscores the significance of these elements and offers a framework for community leaders to champion public health by disseminating affirmative messages regarding HPV vaccination. By gaining a deeper insight into the challenges at hand, community leaders can engage in the process of clarifying misconceptions surrounding HPV vaccines and fostering community backing for immunization initiatives. This approach can prove especially beneficial in areas where access to healthcare is restricted, as local leaders can act as reliable intermediaries connecting the community with healthcare services.

Individuals engaged in the fields of public health, immunology, and healthcare policy are likely to derive significant knowledge from this study. This research provides an insightful case study for students, particularly those in the fields of healthcare, public health, and social sciences, highlighting the intricate challenges associated with vaccine implementation in a low- to middle-income country context. This emphasizes the convergence of healthcare provision with cultural, economic, and policy matters, providing a comprehensive view of the tangible challenges faced in public health. This study serves as a pivotal basis for subsequent inquiries into vaccine hesitancy, health education, or healthcare accessibility in analogous contexts, thereby enriching the broader discourse aimed at enhancing vaccination rates and mitigating HPV-related health risks.

1.7 Scope of the study

Broadly, this study focus is to critically evaluate the challenges to HPV vaccination in Nigeria. Empirically, the study will explore the level of awareness and knowledge about HPV and HPV vaccination among different demographic groups in Nigeria, the socio-cultural barriers influencing perceptions and acceptance of the HPV vaccine among Nigerian communities, the impact of logistical and infrastructural challenges on the distribution and accessibility of the HPV vaccine in rural and urban areas and the relationship between sexual practices and the financial and policy-related constraints affecting the implementation and sustainability of HPV vaccination programs in Nigeria

Geographically, the study will be carried out in Calabar, Cross River State.

1.8 Limitations of the study

Throughout the examination, the researchers carefully came across the inherent constraints that are present in all human behaviors. A significant challenge we faced was the lack of thorough scholarly investigation into the subject matter. A significant factor that contributed to the issue was the limited availability of data regarding the assessment of the challenges to HPV vaccination in Nigeria. The endeavor posed significant difficulties in acquiring the requisite materials, literature, or information, along with the methodical organization of the data, demanding a considerable investment of time and effort.

Moreover, the findings of the study may be constrained by the limited sample size and the specific scope of the research, which predominantly concentrates on Calabar, Cross River State. As a result, the findings of the study hold limited practical relevance, highlighting the need for further exploration.

Moreover, the individual faced significant constraints arising from monetary limitations. As a person with limited financial resources, they had to carefully navigate these constraints throughout their educational journey. The elevated transportation costs at the research site posed a significant obstacle in meeting the financial obligations related to travel expenses.

Furthermore, the individual upheld a rigorous schedule due to their scholarly obligations, which included participating in lectures and partaking in diverse educational pursuits.

1.9 Definition of terms

Prevalence: Prevalence is a term that means being widespread and it is distinct from incidence. Prevalence is a measurement of all individuals affected by the disease at a particular time, whereas incidence is a measurement of the number of new individuals who contract a disease during a particular period of time

Knowledge: Knowledge is an awareness of facts, a familiarity with individuals and situations, or a practical skill

Attitude: Attitude can be defined as the way in which a person views and evaluates something or someone, a predisposition or a tendency to respond positively or negatively toward a certain idea, object, person, or situation.

Prevention: Prevention is an action taken to decrease the chance of getting a disease or condition

Vaccination: Vaccination is a simple, safe, and effective way of protecting people against harmful diseases, before they come into contact with them. Vaccination is the administration of a vaccine to help the immune system develop immunity from a disease

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