title: Implementation of an HPV vaccination program in Eldoret, Kenya: results from a qualitative assessment by key stakeholders.
abstract: BACKGROUND
  Cervical cancer strikes hard in low-resource regions yet primary prevention is still rare. Pilot projects have however showed that Human Papillomavirus (HPV) vaccination programs can attain high uptake. Nevertheless, a study accompanying a vaccination demonstration project in Eldoret, Kenya, revealed less encouraging outcomes: uptake during an initial phase targeting ten schools (i.e., 4000 eligible girls), was low and more schools had to be included to reach the proposed number of 3000 vaccinated girls. The previously conducted study also revealed that many mothers had not received promotional information which had to reach them through schools: teachers were sensitized by health staff and asked to invite students and parents for HPV vaccination in the referral hospital. In this qualitative study, we investigate factors that hampered promotion and vaccine uptake.
  
  
  METHODS
  Focus group discussions (FGD) with teachers (4) and fathers (3) were organized to assess awareness and attitudes towards the vaccination program, cervical cancer and the HPV vaccine, as well as a FGD with the vaccinators (1) to discuss the course of the program and potential improvements. Discussions were recorded, transcribed, translated, and analyzed using thematic analysis In addition, a meeting with the program coordinator was set up to reflect upon the program and the results of the FGD, and to formulate recommendations for future programs.
  
  
  RESULTS
  Cervical cancer was poorly understood by fathers and teachers and mainly linked with nonconforming sexual behavior and modern lifestyle. Few had heard about the vaccination opportunity: feeling uncomfortable to discuss cervical cancer and not considering it as important had hampered information flow. Teachers requested more support from health staff to address unexpected questions from parents. Non-uptake was also the result of distrust towards new vaccines. Schools entering the program in the second phase reacted faster: they were better organized, e.g., in terms of transport, while the community was already more familiarized with the vaccine.
  
  
  CONCLUSIONS
  Close collaboration between teachers and health staff is crucial to obtain high HPV vaccine uptake among schoolgirls. Promotional messages should, besides providing correct information, tackle misbeliefs, address stigma and stress the priority to vaccinate all, regardless of lifestyle. Monitoring activities and continuous communication could allow for detection of rumors and unequal uptake in the community.
authors.affiliation: International Centre for Reproductive Health, Ghent University, De Pintelaan 185, 9000, Ghent, Belgium. Heleen.vermandere@ugent.be.
authors.forename: Heleen
authors.initials: H
authors.lastname: Vermandere
authors.affiliation: Department of Behavioral Sciences, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya. vnaanyu@gmail.com.
authors.forename: Violet
authors.initials: V
authors.lastname: Naanyu
authors.affiliation: International Centre for Reproductive Health, Ghent University, De Pintelaan 185, 9000, Ghent, Belgium. Olivier.degomme@ugent.be.
authors.forename: Olivier
authors.initials: O
authors.lastname: Degomme
authors.affiliation: International Centre for Reproductive Health, Ghent University, De Pintelaan 185, 9000, Ghent, Belgium. Kristien.michielsen@ugent.be.
authors.forename: Kristien
authors.initials: K
authors.lastname: Michielsen
mesh_terms: D000293:Adolescent; D000328:Adult; D002648:Child; D003142:Communication; D005178:Faculty; D005220:Fathers; D005260:Female; D017144:Focus Groups; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D017589:Immunization Programs; D007630:Kenya; D008297:Male; D027383:Papillomaviridae; D030361:Papillomavirus Infections / Q000517:prevention & control* / Q000821:virology; D053918:Papillomavirus Vaccines; D010342:Patient Acceptance of Health Care; D036301:Qualitative Research; D012574:Schools; D012725:Sexual Behavior; D002583:Uterine Cervical Neoplasms / Q000517:prevention & control* / Q000821:virology; D014611:Vaccination
chemical_list: D053918:Papillomavirus Vaccines