CHAPTER ONE: INTRODUCTION

1.1. Background

Cervical cancer is a type of malignant tumor that develops in the epithelial cells of the cervix[1]. Cervical cancer is a public health problem with huge burden globally especially in low- and middle-income countries (LMICs). Worldwide, it is the fourth most common cancer amongst women with estimated 604 000 new cases and 342 000 deaths in 2020[2]. Cervical cancer incidence and mortality are highest in sub-Saharan Africa (SSA), Central America and South-East Asia. These regional disparities in the cervical cancer burden are due to unequal  access to vaccination, screening and treatment services[2]. In Cameroon, cervical cancer is the second most common cancer amongst women with an estimated 2,770 new cases and 1,787 deaths each year [3].

Cervical cancer results from chronic human papilloma virus (HPV) infection of the uterine cervix. HPV is a group of more than 200 DNA stranded viruses, which are spread through vaginal, anal, or oral sex. They can be classified into two groups: low risk and high risk viruses[4]. The most frequent strains of the high risk group are HPV 16 and HPV 18, which are responsible for most HPV-related cancers[5]. Several studies have shown a causal association between HPV and cervical cancer[6–14],and also association between HPV and other HPV-related cancers[15–19]. The prevalence of HPV infection has been estimated in several studies ranging from 13.0% to 33.2%[20–23]. In Cameroon, Doh et al., in 2017 reported an HPV prevalence of 36.3% with HPV types 16, 18 and 45 reported to be the most frequent strains[24].

There are several ways to prevent HPV- related diseases including  HPV vaccination at the age of 09-14 years old, regular screening for cervical cancer, use of condoms, limit number of sexual partners, not smoking or cessation of smoking etc..[25]. Vaccination offers a potentially useful preventive opportunity to adolescents as it offers immunity before potential exposure to HPV through sexual activity. HPV vaccine has a good efficacy with estimated efficacy rates of 90% [26,27]. In the 10 years after the vaccine was recommended in 2006 in the United States, Quadrivalent type HPV infections decreased by 86% in female teens aged 14 to 19 years and 71% in women in their early 20s[28]. A study carried out in 2019 by Brisson et al on the impact of vaccination and screening on cervical cancer in 78 LMICs showed that there is a decline in the prevalence of vaccine-type HPV by 73–85%, and declines in the prevalence of high grade lesions (cervical intraepithelial neoplasia, grade 2 or worse) by 41–57% among young women, less than 10 years after implementation of HPV vaccination [29]

The uptake of HPV vaccine among adolescents varies from country to country [30–34]. Thinley et al reported an overall uptake of HPV vaccine of 61.69% in a meta-analysis(47 studies) involving 24 LMICs from 2008-2020 [35]. The coverage of HPV vaccine in Cameroon is  low and was reported at 5.89% in 2022 [36] probably because it was only introduced in the expanded program of immunization(EPI) in November 2020 targeting females aged 09-14 years old [3]. There is paucity of literature on factors associated with uptake of the vaccine in Cameroon including health facility performance and factors associated with such performance. Therefore, in order to improve this policy, this study seeks to evaluate the uptake of HPV vaccine in various health facilities in Bamenda. 

1.2. Problem Statement

Cervical cancer is a public health problem worldwide and in Cameroon in particular. The highest rates of cervical cancer incidence and mortality are in SSA. Regional differences in the cervical cancer burden are related to inequalities in access to vaccination, screening and treatment services[2]. HPV related diseases have a high burden; Cervical cancer in particular is among the leading causes of cancer-related deaths; the second among women in Cameroon [3,24]. Several studies conducted in LMICs including Kenya, Uganda, Ethiopia and Nigeria has shown that HPV vaccine coverage is low[30–34] despite the proven effectiveness of the vaccine in preventing HPV-related diseases. Hospital related factors for HPV vaccination performance have not been evaluated in Bamenda, Cameroon.

1.3. Justification

HPV related diseases such cervical, vaginal and vulva cancers along with genital warts pose a significant public health burden. Immunizing children at an early age provides the opportunity to achieve the higher vaccine effectiveness and primary prevention against HPV infections by capturing them before potential HPV exposure. Furthermore, previous studies on HPV vaccination in Cameroon, failed to identify determinants of vaccine use or no use. Health facilities could be good points to enroll children or sensitize their parents for vaccination. Unfortunately, there is no data to the best of our knowledge on hospital related factors for HPV vaccination. This information will be useful drive policy that will aim at improving hospital performances and thus improve HPV vaccination coverage which is currently too low.

1.4. Research Questions

1. What is the HPV vaccination coverage in two health districts in Bamenda?
2. 2. What health facility related factors are associated with a high uptake of HPV vaccine?
3. What are the characteristics of the health facilities that offer the vaccine?

1.5. Research Hypothesis

There may be no hospital-based factors associated with HPV vaccine uptake.

1.6. Research Objectives

1.6.1. General Objective

To evaluate the uptake of HPV vaccination in the various health facilities providing HPV vaccine in 2 health districts of Bamenda.

1.6.2. Specific Objectives

1. To list the health facilities that offer HPV vaccination in the Bamenda and Bamenda 3 health districts.
2. To determine the vaccination coverage of HPV vaccine in the health facilities.
3. To identify health facility related factors associated with HPV vaccine uptake.

1.7. Research Goal

The goal of this study is to provide data in our setting on the vaccination coverage of HPV vaccine in the different health facilities thereby creating awareness and sensitization on the effectiveness and importance of immunization before potential HPV exposure.

1.8. Research Scope

The study was limited to all health facilities that offer HPV vaccine in two health districts of Bamenda.