Research from various regions shows varying levels of HPV vaccine acceptability among parents. In developed countries such as the U.S. and U.K., initial studies indicated high vaccine acceptance despite low HPV awareness. Similarly, high acceptability was observed in Argentina and Indonesia, where parents expressed a willingness to vaccinate their daughters if the vaccine was affordable. In Africa, acceptability ranges from 59% to 100%, with countries like Nigeria and Kenya reporting a strong willingness to vaccinate [12] . In Zambia, studies on HPV vaccine acceptability are limited. However, early data suggest that social and cultural beliefs, along with the affordability and accessibility of vaccines, play a crucial role in shaping parental attitudes [13] .

Since Zambia introduced the HPV vaccine into its routine immunization schedule in 2018 [14] , vaccine uptake has faced challenges, primarily due to limited awareness about the vaccine’s importance. A recent study conducted in Lusaka showed that the acceptability of the HPV vaccine among mothers was influenced by socio-economic factors and healthcare access, with more affluent and educated families showing higher acceptability [15] .

Educational level, employment status, and income have been identified as significant factors influencing vaccine acceptability globally. In Zambia, these same factors are likely at play. Higher education levels tend to correlate with greater knowledge of HPV and increased vaccine acceptance, as has been observed in other African countries [16] . Furthermore, families with higher income levels are more likely to have access to healthcare services and preventive measures, including vaccinations. Conversely, unemployment and lower income levels are associated with decreased vaccine uptake in many developing countries, including Zambia [15] .

Parental knowledge of HPV and its vaccines plays a crucial role in vaccine acceptance. Studies from Zambia indicate that many parents are unaware of the link between HPV and cervical cancer, which significantly impacts vaccine uptake [13] . Efforts to raise awareness about HPV and its prevention through vaccination are crucial to improving vaccine coverage. As seen in other regions, positive beliefs about the vaccine’s efficacy and protection against serious diseases strongly predict vaccine uptake.

Attitudes toward HPV vaccination in Zambia, as in many other parts of the world, are shaped by cultural, religious, and social beliefs. In some Zambian communities, traditional beliefs and misinformation about vaccines may hinder their acceptance. For instance, misconceptions about the vaccine’s potential side effects or concerns that vaccination may promote promiscuity have been noted in certain areas [11] . These cultural barriers need to be addressed through community engagement and education to improve vaccination rates.

While global HPV statistics illustrate the severity of the disease, Zambia faces one of the highest incidences of cervical cancer in sub-Saharan Africa. The introduction of the HPV vaccine in Zambia, although significant, has been met with varying levels of acceptance. This study focuses on Ndola District, where understanding maternal acceptability of the HPV vaccine is critical to improving vaccination coverage and reducing cervical cancer incidence.

GENERAL OBJECTIVE

The general objective was to determine HPV vaccine acceptability and its associated factors among mothers of female children aged 9 - 14.

SPECIFIC OBJECTIVES

The specific objectives were:

1) To estimate HPV vaccine acceptability among mothers of female children 9-14 years old.

2) To establish the association between parents; levels of knowledge and acceptance of HPV vaccination.

3) To determine the association between parental attitude and acceptance of HPV vaccination.

4) To determine the association between parental beliefs and acceptance of HPV vaccination.

This survey targeted at mothers to adolescent girls aged 9 - 14 years old.

The study was conducted in Ndola District on the Copperbelt Province of Zambia. Ndola has an estimated population of about Six hundred and fifty-eight thousand (2011) people and 40,454 are mothers in participating sites. The study areas that participated in this study were Kabushi, Chifubu, Kaloko and Lubuto. Figure 1 shows the map of Zambia and the study site.

Details of the breakdown of estimated adolescent populations are presented in Table 1 below.

Table 1. Adolescent population at the study sites.

The study design was a cross-sectional survey in selected townships in Ndola District on the Copperbelt Province of Zambia.

The sample size calculation used the fisher’s exact formula (Jung 2014) as follows:

$\text{Sample}\text{size}=\frac{n}{1+\frac{n}{\text{population}\text{size}}}$

where $n=Z^2\frac{P\left(1-P\right)}{e^2}$

Assuming a response rate of 90%, (161/0.90), the sample size was 350 ( Table 2 ).

Table 2. Values used in the equation.

The calculated sample size is 350 parents.

The total sample size (S.Z.) was allocated per study site using a random sampling of mothers proportionate to adolescents’ population. Therefore, a sampling fraction was calculated and multiplied by the total population at each site to determine the sample size for that site as follows:

Sampling fraction (SF) = sample size/total population.

Therefore, SF (350/161,808) = 0.00216 ( Table 3 ).

Table 3. Sample size distributions per township.

Simple random sampling was implemented to ensure that each eligible household had an equal chance of being selected. A list of eligible mothers was obtained from local health records, and random numbers were generated using statistical software to select participants. This approach ensured that selection bias was minimized, and the sample accurately represented the target population.

Inclusion criteria and Exclusion criteria: Inclusion criteria were limited to mothers of female children aged 9 - 14 years who provided informed consent and were able to comprehend the language used in the questionnaire. Language comprehension was assessed through a brief interview or screening with open-ended questions to evaluate the participant’s ability to understand and respond accurately in the study language. An evaluation of prior education records to confirm language instruction in the study language or related proficiency level was also done.

This ensured that language comprehension was adequately assessed and helped minimize bias, Those who demonstrated difficulty in understanding the language were excluded to prevent misinterpretation of survey questions, which could introduce bias.

After getting the number of households from the central statistical office, the calculated sample size was allocated proportionally to the population’s size in each town. Parents from each town were selected using simple random sampling .10 data collectors, and two supervisors collected data. Data clerks were trained to recruit and interview participants using a simple random sampling of households at intervals in any direction. A structured questionnaire was used to collect the study data. Only one mother was interviewed per household. Parents’ addresses with children aged 9 - 14 for those in school and those out of school were collected from respective schools in the catchment area. All these activities were done in compliance with health guidelines under COVID-19 like wearing masks by data collectors, washing or sanitizing of hands, a social distance of at least one meter from the respondent was maintained.

Data Collection: A community-based cross-sectional study was conducted among parents of girls aged 9 - 14 years in Kaloko, Kabushi, Lubuto, and Chifubu areas within Ndola district, Zambia. Eligible participants were parents aged 18 or older who were available during data collection. The study utilized a structured questionnaire covering demographics, acceptability, knowledge, attitudes, and beliefs regarding the HPV vaccine. Knowledge was evaluated using “Yes,” “No,” or “Do not know” responses, while attitudes, beliefs, and acceptability were assessed through a five-point Likert scale (1 = strongly disagree to 5 = strongly agree).

Data Analysis: Mean scores were computed for knowledge, attitudes, beliefs, and acceptability of the HPV vaccine. Participants scoring above the mean were categorized as knowledgeable, while those scoring below were considered unknowledgeable. Attitudes, beliefs, and acceptability were similarly classified.

Statistical analysis was performed with SPSS version 20. Both adjusted and unadjusted odds ratios with 95% confidence intervals were reported. The assumptions for logistic regression were checked for variables such as age, education, religion, income, occupation, lifestyle factors (alcohol consumption, smoking), medical history (abnormal pap smear, cervical cancer), and knowledge, beliefs, and attitudes toward the HPV vaccine. Binary logistic regression initially identified factors associated with HPV vaccine acceptability, with predictors showing a p-value ≤ 0.25 included in a final multivariable logistic regression model using a backward stepwise selection method. The final model identified income, education level, alcohol consumption, and knowledge of the HPV vaccine as significant predictors of acceptability. Statistical significance was set at p < 0.05 [17] .

Ethical approval was obtained from the Ethics Review Committee at the Tropical Disease Research Center (TDRC) and the National Research Health Authority. Written consent was obtained from each participant, with assurance of their right to withdraw from the study at any point without consequence. Although there was no direct benefit to participants, the findings aimed to benefit the wider community. Minimal risk was posed, and confidentiality was maintained by conducting surveys in safe locations chosen by participants and excluding personal identifiers from collected data.

This study identified that 61.8% of participants were willing to vaccinate their children against HPV, a rate below the WHO-recommended coverage of 80% [21] [22] . Similar findings have emerged globally: in Malaysia, 63% of parents expressed willingness to vaccinate despite existing awareness of the vaccine. Comparatively, Sub-Saharan African countries like Botswana and Kenya reported higher acceptance rates of 88% and 88.1%, respectively [7] . In Nigeria, maternal acceptability was also high at 89.1% [2] , whereas, in Northeastern China, vaccine acceptability was significantly lower at 39.6% among mothers of female children [23] .

Socioeconomic status (SES) impacts health standards and vaccination acceptance. In this study, unemployed parents were less likely to accept HPV vaccination for their children compared to employed parents who could afford quality healthcare services. Research in Malaysia corroborates these findings, showing employed parents are twice as likely to vaccinate their children compared to unemployed parents [24] . Similar trends were found in Norway and Denmark, where employment positively influenced vaccination rates [25] . These findings highlight the importance of community outreach programs, such as health presentations and vaccinations, particularly in low-income areas to improve HPV vaccine access [26] .

Lifestyle factors, including alcohol consumption, were significantly associated with HPV vaccine acceptability. Parents who abstained from alcohol were more likely to accept the vaccine for their children. In Kenya, similar findings suggest that alcohol consumption may negatively impact parental adherence to vaccine schedules [27] . A study in Thailand linked parental alcohol consumption to diminished healthcare adherence. To address this, government policies could focus on mitigating the negative consequences of harmful alcohol use on vaccination compliance.

This study demonstrated that higher knowledge levels about the HPV vaccine correlate with greater acceptability among parents. Vaidakis et al. (2017) observed that supportive beliefs and good knowledge positively influenced vaccine acceptance. Consistent with the Health Belief Model [8] , knowledge mediates individual beliefs and behaviors. Studies across Romania and South Africa reported varying knowledge levels, with 88.5% of Romanian participants aware of HPV, while only 48% of South Africans were knowledgeable despite vaccine licensing [28] [29] In Nigeria, good knowledge of HPV and cervical cancer correlated with a 39.6% acceptance rate [1] .

The Global Vaccine Action Plan emphasizes universal access to vaccinations, which aligns with Zambia’s commitment to a free-of-charge, effective vaccination program with over 95% coverage. The successful integration of HPV vaccination is essential to achieving Zambia’s strategic health objectives, including reducing cervical cancer incidence (Zambia Comprehensive Plan, 2015) [30] .