Bridging the service gap: health facility challenges in HPV vaccine uptake in rural Uganda

Cervical cancer remains a major cause of morbidity and mortality among women in Uganda. Although the Human Papillomavirus (HPV) vaccine is highly effective in preventing cervical cancer, completion of the recommended two-dose schedule remains low, particularly in rural settings. Rukiga District was selected for this study due to persistently low HPV second-dose (HPV2) completion rates compared with national targets. This study assessed health facility-level barriers influencing HPV vaccine completion among adolescent girls aged 9-14 years in rural Uganda.

A mixed-methods cross-sectional study was conducted between June and September 2022 in selected Health Centre II (HC II), Health Centre III (HC III), and Health Centre IV (HC IV) facilities in Rukiga District. A household survey involving 292 caregivers of eligible adolescent girls was conducted using systematic random sampling. The primary outcome was completion of the two-dose HPV vaccination schedule (HPV2). Quantitative data were analysed using logistic regression to identify factors associated with vaccine completion. In addition, 21 key informant interviews involving 11 healthcare workers and 10 Village Health Team (VHT) members were conducted and analysed thematically to explore contextual barriers affecting HPV vaccine uptake and completion.

The HPV vaccine completion rate was 23.49%, indicating low coverage. In multivariable analysis, vaccine stock-outs and cold-chain challenges (adjusted odds ratio [AOR] = 1.75, 95% confidence interval [CI]: 1.04-2.93; p = 0.004) and understaffing of healthcare workers (AOR = 1.97, 95% CI: 1.05-3.68; p = 0.006) were the only statistically significant predictors of HPV vaccine completion. Although limited healthcare worker knowledge (AOR = 0.94, 95% CI: 0.70-1.24) and absence of government programmes targeting out-of-school girls (AOR = 0.97, 95% CI: 0.73-1.29) were not statistically significant in the adjusted model, qualitative findings highlighted them as important contextual barriers. Additional challenges identified included weak outreach systems, transportation constraints, misconceptions about HPV vaccination, and limited community awareness.

HPV vaccine completion in rural Uganda remains low and is strongly influenced by health system constraints, particularly vaccine supply-chain disruptions and human resource shortages. Strengthening vaccine logistics, improving staffing levels, enhancing healthcare worker capacity, and expanding outreach strategies targeting underserved populations are essential for improving vaccine completion and achieving national immunisation targets.