Associated Factors with Vaccination among Girls Aged between (11) and (13) against Papillomaviruses in Koumpentoum Health District (Senegal)

Introduction: Cervical cancer can be prevented by early vaccination of young people against papillomaviruses and screening for precancerous lesions. After a successful pilot phase, vaccination coverage in the generalization phase is low. The aim of this study was to determine papillomavirus vaccination coverage and to identify associated factors. Methods: This was a cross-sectional, descriptive and analytical study conducted from (1 st ) to (31 th ) September (2020) in Koumpentoum district. After a literature review, we conducted two-stage cluster sampling and direct structured interviews. Socio-demographic characteristics, knowledge, attitudes, and practices of mothers or guardians about papillomaviruses vaccination were collected us-ing a standardized questionnaire. Multiple logistic regression was used to estimate odds ratios. Results: A total of (228) mothers or guardians were inter-viewed. Coverage for the first dose was (44.74%) CI 95% (38.17 - 51.44) compared to (25.88%) CI 95% (19.52 - 31.17) for the second dose. Factors statistically and significantly associated with coverage of the first dose of papilloma-viruses vaccine were instruction of mothers or guardians (OR =


Abstract
Introduction: Cervical cancer can be prevented by early vaccination of young people against papillomaviruses and screening for precancerous lesions. After a successful pilot phase, vaccination coverage in the generalization phase is low. The aim of this study was to determine papillomavirus vaccination coverage and to identify associated factors. Methods: This was a cross-sectional, descriptive and analytical study conducted from (1 st ) to (31 th ) September (2020) in Koumpentoum district. After a literature review, we conducted two-stage cluster sampling and direct structured interviews. Socio-demographic characteristics, knowledge, attitudes, and practices of mothers or guardians about papillomaviruses vaccination were collected using a standardized questionnaire. Multiple logistic regression was used to estimate odds ratios. Results: A total of (228) mothers or guardians were interviewed. Coverage for the first dose was (44.74%) CI 95% (38.17 -51.44) compared to (25.88%) CI 95% (19.52 -31.17) for the second dose. Factors statistically and significantly associated with coverage of the first dose of papillomaviruses vaccine were instruction of mothers or guardians (OR = 5.62 (3. 16 -9.99); p < 0.001), schooling of the young girls (OR = 4.1 (2.23 -7.53); p < 0.001), information on cervical cancer (OR = 18.97 (5.68 -63.24); p < 0.001), knowledge of risks factors (OR = 8.04 (4.41 -14.63

Introduction
Cervical cancer develops in the anatomical part of the female reproductive system that separates the vagina from the uterus. Almost all cases are due to chronic infection with the human papillomavirus (HPV), making it a preventable and curable cancer [1]. It is the (4th) most common cancer in women, with approximately (604,000) new cases. It is also the (2 nd ) most common female cancer in less developed regions, which accounts for (85%) of new cases. In (2020), cervical cancer caused (320,000) deaths worldwide [2]. Almost all, or 90% of these deaths, occurred in developing countries, particularly in sub-Saharan Africa, where it is steadily and markedly increasing [3] [4].
Caroline D et al. in their systematic review conducted in sub-Saharan Africa with a majority of articles from South Africa, Uganda and Kenya, found that the causes of non-vaccination against HPV were lack of information of mothers or guardians and fear of infertility associated with the disease [9].
What are the factors associated with HPV vaccination coverage in the Koumpentoum health district? The objective of this research was to determine HPV  (11) and (13) years and to identify associated factors in order to make recommendations for improvement.

Study Framework
The population of the district was estimated in (2020) at (164,409) inhabitants on a surface area of (7652) km 2 , or a density of (21.48) inhabitants/km 2 . The town of Koumpentoum is home to the health centre, which provides reference activities and also offers primary health care (PHC). It polarizes (22) health posts that only offer PHC. The expanded program of immunization (EPI) target is accessible to (51%) in fixed and displaced fixed strategy, (35%) in advanced and (14%) in mobile [10].

Study Type and Period
This was a cross-sectional, descriptive and analytical study. Data collection period was from (1 st ) to (30 th ) September (2020) throughout the district.

Study Population
The study population consisted of girls aged between (11) and (13) years. However, for ethical and cultural reasons, mothers or guardians were interviewed.

Inclusion and Non-Inclusion Criteria
Mothers or guardians of girls aged between (11) and (13) years who refused to participate were absent or ill at the time of the survey were not included. Similarly, girls aged (11) to (13) years who refused to participate were absent or ill at the time of the survey were not included.

Study Variables
The dependent variable was the uptake of the first dose of HPV vaccine by girls aged between (11) and (13) years. The independent variables were related to socio-demographics, knowledge about cervical cancer and the HPV vaccine, attitudes towards EPI and HPV vaccination and HPV vaccination practices.

Data Collection
We used an HPV vaccination data collection form and administered a closed questionnaire directly to the mothers or guardians of young girls aged between (11) and (13) years.

Pre Test
A pre-test was carried out with (30) mothers or guardians of young girls aged between (11) and (13) years in the health centre area with the administration of the survey forms and the stabilization of the data entry mask. The pre-test data were not included in the analysis.

Data Management and Analysis
Preparation of the data entry mask in Epi-info version (7.2) made it possible to constitute a database. Data analysis was carried out with the softwares Epi Info  (20) and R version (4.05). In descriptive part, the quantitative variables were described with their extremes, means and standard deviations, while the qualitative variables were described with their frequencies surrounded by their confidence intervals (CI) at (95%). In the bivariate analysis part, the Pearson's chi2 statistical test and the Fisher's test under conditions of applicability verified existence of statistically significant relationships.
Multiple logistic regression was used for the multivariate analysis. All independent variables with a p < (0.25) in the bivariate analysis and those for which the literature review revealed a link with the dependent variable. A stepwise top-down approach was used to retain variables associated with vaccination at the p < (5%) threshold. These were then removed one by one with a nested model comparison by the Aikake information criterion (AIC) [13] until no improvement was found by the maximum likelihood test. The Hosmer-Lemoshow test [14] was used to check the fit of the final model. The bivariate OR and multivariate adjusted OR with their (95%) CIs were used to assess the strength of the relationship between the independent and dependent variables.

Ethical Considerations
The study protocol was submitted to the health authorities for approval. The survey was explained to the participants through an information letter read in the local language. Free consent was collected on a form and signed by mothers or guardians who consented to the survey. Data collected remained anonymous

Description of the Study Population
In this study, (228) mothers or guardians were interviewed.

Bivariate Analysis
In bivariate analysis, statistically and significantly factors associated with cover-

Limitation of the Study
Although the target was girls aged between (11) and (13)   and Koranic masters were not interviewed to collect their knowledge, perceptions, attitudes and practices and to question their influences on HPV vaccination.

Discussion
Factors statistically and significantly associated with coverage of the first dose of the HPV vaccine were instruction of mothers or guardians (OR = 5.62 (3.16 -9.99); p < 0.001), schooling of the young girls (OR = 4.1 (2.23 -7.53); p < 0.001),  In our sample, there was no association between the place of residence of mothers or guardians and HPV vaccination of young girls, contrary to the results of North American [15] and Chinese [16] [17] [18] authors. Indeed, the latter found that overall HPV vaccination coverage was higher in developed countries and urban areas than in developing countries and suburban and rural areas. However, Faye et al. in Kaffrine found the opposite with higher HPV vaccination coverage in rural areas [19]. This lack of difference in our sample can be explained by the fact that the department of Koumpentoum is essentially rural and does not have any large cities [10].
The age of the mothers or guardians was not associated with the vaccination of the young girl in accordance with the results found in national series such as Faye et al. [19] and Ndiaye et al. [20]. However, one might expect greater receptivity on the part of young mothers or guardians and greater mobility and at-tendance at health facilities due to cultural realities.
We did not find an association between mothers or guardian's marital status and girl's vaccination, as in the series by Ndiaye et al. [20]. However, the educa-  [7]. Indeed, the target young girls aged between (9) and (14) are mainly in primary and secondary school. Consequently, awareness, involvement and collaboration with the national education sector are imperative in order to reach this school target and the vaccination coverage objective of (90%).

Conclusion
The information provided to mothers or guardians is crucial to achieving the vaccination coverage target. Factors associated with low HPV vaccination coverage in the Koumpentoum health district are related to mothers' or guardians' lack of knowledge, which is a consequence of insufficient and inadequate communication. HPV vaccination coverage could be significantly improved through an acceleration plan focusing on interpersonal communication and involving national education sector.