Overview
Human papillomavirus (HPV) can lead to cervical cancer and other diseases, with Africa bearing a significant share of the global burden. In sub-Saharan Africa (SSA), vaccination programs have expanded in recent years, but parental awareness and acceptance remain uneven. This systematic review and meta-analysis synthesize evidence on how socioeconomic factors—education, income, occupation, and urban versus rural residence—are associated with parents’ awareness of and willingness to vaccinate their daughters against HPV.
Key questions and scope
The review asked: Do socioeconomic factors influence (1) parental awareness of the HPV vaccine and (2) parental acceptability of vaccinating their daughters in SSA? It also explored whether associations differ before versus after national HPV vaccination programs and between mothers and fathers. The evidence base includes 26 observational studies, mainly cross-sectional, from 7 SSA countries with Nigeria and Ethiopia contributing the largest number of studies.
Education and parental awareness
Among studies examining education and awareness, higher parental education—particularly tertiary education—consistently correlated with greater awareness of HPV vaccination. Pooled results indicated that parents with tertiary education were more aware than those with lower education levels (pooled odds ratio around 3.8). However, there was substantial heterogeneity, likely due to differences in study design, timing relative to program introduction, and measurement of awareness. In subgroup analyses, the education-awareness link appeared stronger in studies conducted before widespread national vaccination programs, suggesting evolving information landscapes after program rollouts.
Other SES factors and awareness
Income showed a positive but imprecise association with awareness: moderate to high income sometimes corresponded to higher awareness, but pooled estimates were imprecise with wide confidence intervals and high heterogeneity. Urban versus rural residence data were limited, but one study found urban parents much more likely to be aware, while another suggested rural awareness could be higher in some settings. Occupation results were mixed, with skilled workers sometimes showing greater awareness, but findings varied by country and study.
Education and parental acceptability
Education again stood out as a key driver of acceptability. Across 16 studies, parents with tertiary education were roughly twice as likely to be willing to vaccinate their daughters compared with those with lower education. Yet, heterogeneity was high, and some studies reported no clear association or even inverse trends in certain contexts. Subgroup analyses revealed stronger education-acceptability links before national HPV programs were introduced, with the association narrowing after programs were in place as information campaigns broadened reach.
Income, residence, and occupation with acceptability
Higher income generally aligned with greater acceptance of HPV vaccination, with pooled analyses showing higher odds of acceptance among high-income parents (though with substantial heterogeneity). Urban residence tended toward higher acceptability in most studies, while results for occupation were mixed—some settings linked skilled workers with greater acceptance, others found no clear pattern. The overall certainty of evidence for these associations was low to very low, reflecting variability and study limitations.
Certainty and implications for policy
The GRADE assessment across meta-analyses indicated low to very low certainty, largely due to observational designs, heterogeneity, and small study sizes. Despite these limitations, findings consistently point to education as a strong correlate of both awareness and acceptability of HPV vaccination in SSA. This implies that vaccination programs should align with strategies that elevate health literacy and provide clear, trustworthy information through healthcare workers, schools, and community channels, especially targeting groups with lower educational attainment.
Practical strategies to improve uptake
– Integrate HPV vaccination into routine immunization and implement school-based delivery to reach both in- and out-of-school girls.
– Reduce cost barriers and improve access via mobile clinics and outreach services, particularly in rural or underserved areas.
– Tailor information campaigns to different education levels, ensuring messages about vaccine safety, cancer prevention, and the importance of early vaccination are accessible and culturally appropriate.
– Engage parents through trusted healthcare providers and community leaders to build trust and counter misconceptions about fertility and sexual activity.
Conclusion
Socioeconomic factors, especially education and income, appear linked to parental awareness and acceptance of HPV vaccination in SSA, with higher education consistently associated with greater awareness and willingness to vaccinate. While evidence quality varies, these patterns highlight the need for equity-centered vaccination programs that address educational and access barriers, ensuring that all girls in SSA have the opportunity to benefit from HPV vaccination and cervical cancer prevention.
