title: Access and Attitudes to HPV Vaccination amongst Hard-To-Reach Populations in Kenya.
abstract: BACKGROUND
  Sub-Saharan Africa bears the greatest burden of cervical cancer. Human papillomavirus (HPV) vaccination programmes to prevent the disease will need to reach vulnerable girls who may not be able access health and screening services in the future. We conducted formative research on facilitators and barriers to HPV vaccination and potential acceptability of a future HPV vaccination programme amongst girls living in hard-to-reach populations in Kenya.
  
  
  METHODS
  Stakeholder interviews with Ministry of Health staff explored barriers to and support for the uptake of HPV vaccination. A situation assessment was conducted to assess community services in Maasai nomadic pastoralist communities in Kajiado County and in Korogocho informal settlement in Nairobi city, followed by focus group discussions (n=14) and semi-structured interviews (n=28) with health workers, parents, youth, and community and religious leaders. These covered marriage, knowledge of cervical cancer and HPV, factors that might inhibit or support HPV vaccine uptake and intention to accept HPV vaccine if a programme was in place.
  
  
  RESULTS
  Reported challenges to an HPV vaccination programme included school absenteeism and drop-out, early age of sex and marriage, lack of parental support, population mobility and distance from services. Despite little prior knowledge of cervical cancer and HPV, communities were interested in receiving HPV vaccination. Adequate social mobilisation and school-based vaccination, supplemented by out-reach activities, were considered important facilitating factors to achieve high coverage. There was some support for a campaign approach to vaccine delivery.
  
  
  CONCLUSIONS
  Given the high level of support for a vaccine against cervical cancer and the experience of reaching pastoralist and slum-dwellers for other immunizations, implementing an HPV vaccine programme should be feasible in such hard-to-reach communities. This may require additional delivery strategies in addition to the standard school-based delivery, with vaccine offered at multiple venues, potentially through a campaign approach.
authors.affiliation: London School of Hygiene & Tropical Medicine, Keppel Street, London, United Kingdom; Mwanza Intervention Trials Unit, National Institute for Medical Research, Mwanza, Tanzania.
authors.forename: Deborah
authors.initials: D
authors.lastname: Watson-Jones
authors.affiliation: Kenya Medical Research Institute, Nairobi, Kenya.
authors.forename: Nelly
authors.initials: N
authors.lastname: Mugo
authors.affiliation: London School of Hygiene & Tropical Medicine, Keppel Street, London, United Kingdom.
authors.forename: Shelley
authors.initials: S
authors.lastname: Lees
authors.affiliation: University of Nairobi, Nairobi, Kenya.
authors.forename: Muthoni
authors.initials: M
authors.lastname: Mathai
authors.affiliation: University of Nairobi, Nairobi, Kenya.
authors.forename: Sophie
authors.initials: S
authors.lastname: Vusha
authors.affiliation: Division of Reproductive Health, Ministry of Health, Nairobi, Kenya.
authors.forename: Gathari
authors.initials: G
authors.lastname: Ndirangu
authors.affiliation: London School of Hygiene & Tropical Medicine, Keppel Street, London, United Kingdom.
authors.forename: David A
authors.initials: DA
authors.lastname: Ross
mesh_terms: D000293:Adolescent; D002648:Child; D005260:Female; D017144:Focus Groups; D007722:Health Knowledge, Attitudes, Practice; D006297:Health Services Accessibility; D006801:Humans; D007630:Kenya / Q000453:epidemiology; D053918:Papillomavirus Vaccines / Q000276:immunology*; D010342:Patient Acceptance of Health Care; D012725:Sexual Behavior; D002583:Uterine Cervical Neoplasms / Q000453:epidemiology* / Q000517:prevention & control*; D014611:Vaccination
chemical_list: D053918:Papillomavirus Vaccines