Overview
Human papillomavirus (HPV) vaccination is a cornerstone of cervical cancer prevention. In Sub-Saharan Africa (SSA), cervical cancer remains a leading cause of death among women, and national HPV vaccination programs are unevenly implemented across countries. A recent systematic review and meta-analysis synthesized evidence on how parental socioeconomic factors influence awareness and acceptability of HPV vaccination for daughters in SSA, shedding light on barriers and opportunities to improve vaccine coverage.
Key Findings on Awareness and Education
Across 26 studies, higher parental education consistently correlated with greater awareness of the HPV vaccine. Parents with tertiary education were markedly more likely to have heard of or understood the vaccine’s role in cancer prevention than those with primary/secondary education. In the meta-analysis, tertiary education linked to substantially higher awareness (pooled OR ~3.8), though with notable heterogeneity (I2 ~84%). Pre-program implementation periods showed stronger associations, suggesting that education amplified the impact of early information campaigns and health messaging before national programs scaled up.
Income and Awareness
Income showed a positive, but imprecise, association with awareness. Moderate income yielded a small to moderate increase in awareness (pooled OR ~1.22), while high income suggested a more considerable advantage (pooled OR ~1.96). Wide confidence intervals and high heterogeneity temper confidence in these estimates, yet the direction points toward financially advantaged families having better access to information and services.
Residence and Awareness
Evidence linking urban vs. rural residence to awareness was limited but suggestive. Urban parents in one Ethiopian study were substantially more aware than rural peers, whereas a Zimbabwean study indicated a non-significant tendency for rural awareness to be higher. Overall, more robust data are needed to clarify the urban–rural divide in SSA.
Acceptability of HPV Vaccination and Education
Acceptability, or readiness to vaccinate daughters, also showed a positive link with education. Among 16 studies, those with higher education levels tended to be more willing to vaccinate, with a pooled odds ratio around 2.0–3.0 in some analyses. However, heterogeneity was high (I2 up to 77%), driven by variations in country context, program exposure, and measurement approaches. Subgroup analyses revealed that the education-acceptability link was stronger in studies conducted before the national vaccination programs and attenuated after these programs launched, likely due to broader information dissemination and normalization of HPV vaccination.
Income and Acceptability
Income also influenced acceptability. High income was associated with higher willingness to vaccinate (pooled OR ~2.16 in one analysis), though heterogeneity remained substantial. Moderate income showed weaker and less certain effects. These patterns imply that affordability and perceived value influence parental decisions, especially where vaccine out-of-pocket costs or transportation burdens exist.
Residence and Acceptability
Urban residence generally correlated with higher acceptability, echoing trends in awareness. Yet, one high-bias Botswana study suggested the opposite, highlighting the need for cautious interpretation and more methodologically rigorous work.
Occupation and Its Mixed Signals
Occupation yielded inconsistent results. Some studies linked skilled employment with greater awareness and acceptability, while others found no clear pattern. Divergent occupation definitions and small sample sizes contributed to these ambiguities, indicating that occupation alone may be a weak proxy for vaccine-related attitudes in SSA without considering context and access to health information.
Policy Implications
These findings support targeted strategies to reduce disparities in HPV vaccine uptake across SSA. Priorities include:
- Integrating HPV vaccination into routine immunization and expanding school-based delivery to reach both in-school and out-of-school girls.
- Reducing cost and access barriers through subsidies, mobile clinics, and outreach services to underserved areas, which may disproportionately affect lower-income families.
- Leveraging health education campaigns that are tailored to different education levels, with emphasis on trust-building with healthcare providers to improve literacy and uptake.
- Addressing urban–rural gaps by delivering consistent information and vaccination services in rural communities.
Limitations and Future Research
The review covers 26 studies across seven SSA countries, limiting generalizability. High heterogeneity, potential information bias, and reliance on self-reported data temper the certainty of estimates. Future prospective studies with standardized measures, broader country representation, and post-implementation analyses will be essential to clarify how socioeconomic factors shape HPV vaccine awareness and acceptance as SSA programs expand.
Conclusion
In SSA, higher parental education and, to a lesser and more variable extent, higher income are associated with greater awareness and acceptability of HPV vaccination. Contextual factors, such as timing relative to national vaccination programs and urban-rural residence, modulate these associations. Policymakers should design equitable strategies that ensure access to information and vaccination services for all socioeconomic groups to advance cervical cancer prevention across the region.
