title: A qualitative analysis of factors influencing HPV vaccine uptake in Soweto, South Africa among adolescents and their caregivers.
abstract: BACKGROUND
  In South Africa, the prevalence of oncogenic Human Papillomavirus (HPV) may be as high as 64%, and cervical cancer is the leading cause of cancer-related death among women. The development of efficacious prophylactic vaccines has provided an opportunity for primary prevention. Given the importance of psycho-social forces in vaccine uptake, we sought to elucidate factors influencing HPV vaccination among a sample of low-income South African adolescents receiving the vaccine for the first time in Soweto.
  
  
  METHODS
  The HPV vaccine was introduced to adolescents in low-income townships throughout South Africa as part of a nationwide trial to understand adolescent involvement in future vaccine research targeting human immunodeficiency virus (HIV). We performed in-depth semi-structured interviews with purposively-sampled adolescents and their care providers to understand what forces shaped HPV vaccine uptake. Interviews were recorded, transcribed, translated, and examined using thematic analysis.
  
  
  RESULTS
  Of 224 adolescents recruited, 201 initiated the vaccine; 192 (95.5%) received a second immunization; and 164 (81.6%) completed three doses. In our qualitative study of 39 adolescent-caregiver dyads, we found that factors driving vaccine uptake reflected a socio-cultural backdrop of high HIV endemnicity, sexual violence, poverty, and an abundance of female-headed households. Adolescents exercised a high level of autonomy and often initiated decision-making. Healthcare providers and peers provided support and guidance that was absent at home. The impact of the HIV epidemic on decision-making was substantial, leading participants to mistakenly conflate HPV and HIV.
  
  
  CONCLUSIONS
  In a setting of perceived rampant sexual violence and epidemic levels of HIV, adolescents and caregivers sought to decrease harm by seeking a vaccine targeting a sexually transmitted infection (STI). Despite careful consenting, there was confusion regarding the vaccine's target. Future interventions promoting STI vaccines will need to provide substantial information for participants, particularly adolescents who may exercise a significant level of autonomy in decision-making.
authors.affiliation: Brigham and Women's Hospital, Boston, Massachusetts, United States of America ; Harvard Medical School, Boston, Massachusetts, United States of America ; Massachusetts General Hospital Center for Global Health, Boston, Massachusetts, United States of America.
authors.forename: Ingrid T
authors.initials: IT
authors.lastname: Katz
authors.forename: Busisiwe
authors.initials: B
authors.lastname: Nkala
authors.forename: Janan
authors.initials: J
authors.lastname: Dietrich
authors.forename: Melissa
authors.initials: M
authors.lastname: Wallace
authors.forename: Linda-Gail
authors.initials: LG
authors.lastname: Bekker
authors.forename: Kathryn
authors.initials: K
authors.lastname: Pollenz
authors.forename: Laura M
authors.initials: LM
authors.lastname: Bogart
authors.forename: Alexi A
authors.initials: AA
authors.lastname: Wright
authors.forename: Alexander C
authors.initials: AC
authors.lastname: Tsai
authors.forename: David R
authors.initials: DR
authors.lastname: Bangsberg
authors.forename: Glenda E
authors.initials: GE
authors.lastname: Gray
mesh_terms: D000293:Adolescent; D017028:Caregivers / Q000706:statistics & numerical data*; D002648:Child; D003657:Decision Making; D005191:Family Characteristics; D005260:Female; D015658:HIV Infections / Q000453:epidemiology; D040261:Harm Reduction; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D008297:Male; D053918:Papillomavirus Vaccines / Q000008:administration & dosage*; D036301:Qualitative Research; D012742:Sex Offenses; D012749:Sexually Transmitted Diseases / Q000453:epidemiology / Q000276:immunology / Q000517:prevention & control / Q000821:virology; D013019:South Africa / Q000453:epidemiology; D055815:Young Adult
chemical_list: D053918:Papillomavirus Vaccines
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