Cervical cancer is currently a major public health concern and is the commonest killer cancer in developing countries. Nigeria is one of the few countries contributing more than 80% of cervical cancer cases in the world. The place of Human Papilloma Virus (HPV) infection in the causation of cervical cancer is no longer in debate. It is responsible for 99.9% of cases of cervical cancer [1]. Based on this, Merck and GlaxoSmithKline (GSK) developed the quadrivalent (Gardasil) and the bivalent (Cervarix) HPV vaccines respectively using HPV L1 virus like particles. These vaccines became commercially available from 2009 [2]. In 2014, a nonavalent vaccine was developed by Merck. All available vaccines prevent against the high-risk HPV viruses 16 and 18 which are known to be responsible for 70% of cervical  cancers [3]. The World Health Organization has recommended the use of HPV vaccination as a means of primary prevention of cervical cancer and suggests its use in vaccine naive adolescent girls from 9 to 13 years. Several countries of the world have adopted routine eliminating cervical cancer is within reach [1]. There has been debates on the number of doses that will suffice and if a booster will be of use. There is also debate on the utility of giving vaccines to young women who are yet to be infected with the virus. In developing countries, the cost was said to be approximately 47$ for the full dose but could be as high as 200$ in the United States [4]. Most European countries have this vaccine fully covered on the national health insurance scheme but in Africa, vaccine provision is supported by the GAVI alliance and is working only in a few African countries such as Malawi, Rwanda, Ghana, Mozambique, Tanzania, Sierra Leone, Niger and Madagascar [5-6]. In Australia, both boys and girls get the vaccines in schools free of charge. Apart from this, there is herd immunity from just the female program and this could lead to a dramatic drop in cervical cancer rates [1]. In  Nigeria,  the vaccines became available in 2009, but widespread use is yet to  be achieved. There have been conflicting issues surrounding the use of the vaccine, most of which border on ignorance and poverty. Among antenatal attendees at a tertiary hospital, knowledge about HPV vaccine was low [7]. Despite being a good product with proven results in other countries such as Australia and India, there is need for widespread knowledge and acceptability of the vaccine before its use can be valued. Considering that this product is meant for adolescents, the perception and acceptability of their care givers (usually the mothers) will influence uptake of the vaccine. Secondly, there is need for it to be not only available but affordable. The latter can be influenced by the presence of high demand. On the other hand, without knowledge, even when made available it will not be utilized. With the current WHO declaration that HPV vaccination should be used as a weapon against cervical cancer [3], it is pertinent that appropriate and adequate advocacy, health  education and promotion is done on the use of HPV vaccination against cervical cancer It is on this note that this study set out to find baseline knowledge of rural women in a community in Imo state Nigeria on HPV vaccine and their willingness and ability to have their girl children vaccinated.

This cross sectional descriptive study was conducted in a rural village in Imo state, Nigeria. Women attending a free medical outreach targeting cervical cancer screening in a rural community in eastern Nigeria were counselled and consent sought for administration of a 20- item pre-tested questionnaire on the knowledge and acceptability of HPV vaccination in  the prevention of cervical cancer. The questions where both closed and open ended. They captured the following areas; biodata to include-age, tribe, educational status, marital status, coitarche, age at first birth, parity, knowledge of HPV cervical  cancer prevention strategies, source of information, willingness and ability to pay and vaccinate her girl child. The questionnaires were interviewer administered the filled-out questionnaires were collated and analyzed using IBM SPSS version 20.0 for descriptive statistics.

One hundred and forty-one women aged between 35 and 55 years responded to the questionnaire. About half the respondents (73) had only primary education, 22.7% (32) had secondary education, 6.4% (9) had tertiary education while 19.1% (27) had no formal education. Almost all were of Igbo tribe and were all married. More than half, 52.5% (74) of the women had more than four children and well over half (97) had coitarche before 19 years. Eight of the participants (5.7 %) had coitarche before 12 years of age.) Over 80% (115) had never heard of cervical cancer. Those who had heard of it got the information from health campaigns, health facilities and mass media. Close to 95% (134) had never heard of HPV and over 80% (115) had no clue to the cause of cervical cancer or that HPV caused cervical cancer. The very few who had heard of HPV did not know the mode of transmission and only 3.5% associated it with sex. When asked about prevention of cervical cancer, 85.2% (120) did not know and only 1.4% (2) mentioned vaccination. Even though close to 90% (126) of the women will like to vaccinate their girl child, over 80% (113) of the women earned less than N10,000 ($27.7) monthly  and about 55.3% (78) earned nothing on monthly basis. Of those willing to vaccinate their girl child, 106 (84.1%; n=126) wanted it free while 12.7% (16) will be willing to spend only N2000 ($5.8) on the vaccination. Out of all parameters assessed, only educational level was of statistical significance in the knowledge of prevention of cervical cancer (p=0.001) and transmission of the virus (p= 0.012). This was because the correct answers were only from the few women with tertiary education (Tables 1-3).

Table 1: Knowledge about cervical cancer and its prevention.

Table 2: Knowledge about cervical cancer and its prevention.

Table 3: Income and Willingness to Vaccinate Girl Child (N= 141).

This study was carried out in a rural community in Imo state among women attending a medical outreach program on cervical cancer screening. The questionnaire was administered prior to the health education and was able to reflect their knowledge base. Expectedly, this cohort of women were generally of low educational status, had high fertility rates and majority had early coitarche and were of low socio-economic status. The awareness of HPV and cervical cancer was poor in the studied community. The demographic data in this study showed that women nurtured in this environment have most of the predisposing factors for cervical cancer and therefore by extrapolation, the young ones brought up in similar environment may have a likelihood of also having predisposition to cervical cancer. It is therefore very pertinent that in this environment preventive measures such as vaccination will be of import. Unfortunately, knowledge of HPV DNA or HPV vaccines was abysmally low among the mothers. Different studies in rural communities have shown mostly poor awareness of the HPV vaccine by women irrespective of the educational status. The study done at FCT, Abuja showed poor awareness despite a high literacy level [7]. Educational status of women in this study being low resulted in a similar low  awareness level as the study done at Gwagwalada rural community where the awareness was low but contrasts with the rural communities at Ibadan where awareness was high [8-9]. It is established that it is the parents that will sponsor or even permit an under aged child to receive vaccination. This cannot be possible if the parent is unaware of such an option. There is a lot of work required of the health care practitioners in terms of health education and dissemination in the mass and social media in creating awareness on cervical cancer prevention. Granted, those that got the information did so from health campaigns and the health workers, but a lot still needs to be done to keep developing countries be at par with the developed world. Another problem anticipated in the prevention program will be high cost of the vaccines and will lead to a slow roll out of vaccination programmes.  The vaccination was not affordable to the women  in the study community. A child is expected to have a minimum of two doses for protection at the cost of about nineteen thousand naira ($54). The study revealed that most of the women earned below ten thousand naira monthly ($27.7), contrary to the school- based study in Anambra state, were 50% of the women earned $251 monthly. This makes the capacity of such women to sponsor the vaccination on her own to be near impossible. This study, however had the limitation of not enquiring about the income level of the husband of these women and therefore was unable to conclude on family’s ability to sponsor vaccination. Like the study done at Abuja and Lagos, women were willing to accept the HPV  vaccine  for  their  adolescent  daughters  even  though  they were not aware of the virus. The women showed interest to vaccinate their girl children if the vaccine is made available but may not be willing to pay for it. In fact, majority of the women will prefer if it is free of cost or to pay as low as two thousand naira ($5.5) for the full vaccine dose. This may be their perceived value of such a vaccine. It may also be in comparison to the cost of other childhood vaccines which are subsidized or possibly because they cannot afford the vaccine cost. Despite this lack of funds, only 10.6% rejected HPV vaccination for their daughters while others were willing to pay up to the $4.5 per dose that was negotiated by the GAVI alliance in vaccine eligible countries.  In a school -based study, in Anambra state, only 19.1% had ever heard of HPV infection. They were willing to pay an average of US$11.68 which cannot cover the offering price of vaccine by manufacturers [10-11]. For a preventive program to be effective, there is a need to cover a minimum of 80% of the target population [12]. This is unlikely to be achieved from the findings of this study and the onus will need to lie on the government and non- governmental organizations to provide and sponsor this course. The GAVI vaccine alliance had 47 eligible countries in 2018 and had negotiated the price of the HPV vaccine to $4.50  per dose in those countries [13]. To be eligible for GAVI support in 2018, a country must have a Gross national income per capita of less than US$1580 for the three preceding years as reported by World Bank by July 1 of preceding year and DPT immunization coverage of over 90% amongst others. Nigeria’s Gross national income per capita is $2,820 and the DPT coverage is way below 90% [14]. Nigeria is not listed as a beneficiary in the 2018 Gavi vaccine alliance but Nigeria enjoys Gavi support in areas  of health strengthening, immunization support, injection safety, measles, yellow fever, Rota virus and meningitis campaign and prevention [11]. The government needs to take over and make a concerted effort to subsidize the vaccine in Nigeria while creating widespread knowledge on the subject matter.

This study has shown that risk factors for cervical cancer abound and that despite the low knowledge and awareness of HPV, cervical cancer and HPV vaccines, the women  showed willingness to have their daughters vaccinated. The study, however showed that affordability of the vaccine may be an issue. There is therefore a lot of need by the government and non - governmental organizations to work hard at creating awareness, as well as making the vaccine available at affordable/ subsidized prices which should be heavily subsidized. It is pertinent that for cervical cancer to be eradicated, the developing countries must eliminate their contribution to the scourge.

1. Zhou N. Australia could become first country to eradicate cervical The Guardian international edition. 2018.
2. Sangar VC, Ghongane B, Mathur G. Development of Human Papillomavirus HPV Vaccines A Review of Literature and Clinical Rev Recent Clin Trials. 2016; 11: 284-289.
3. World Health Organization. Human papillomavirus vaccines WHO position paper May 2017 Weekly epidemiological record. 2017; 92: 241-268.
4. Fesenfeld M, Hutubessy R, Jit M. Cost-effectiveness of human papillomavirus vaccination in low and middle income countries a systematic review. 2013; 31: 3786-3804.
5. FDA approves Gardasil 9 for prevention of certain cancers caused by five additional types of 2014
6. Professor Ian Frazer creator of the HPV vaccine. Human papillomavirus vaccine-new and underused vaccines support – types of Gavi alliance. Archived from the original on 2014.
7. Agida TE, Akaba GO, Isah AY, Ekele Knowledge  and perception of human papilloma virus vaccine among the antenatal women in a Nigerian tertiary hospital. Niger Med J. 2015; 56: 23- 27.
8. Nnodu O, Erinosho L, Jamda M, Olaniyi  O,  Adelaiye  R,  Lawson L, et al. Knowledge and attitudes towards cervical cancer and human papilloma virus A Nigerian Pilot Afr J Reprod Health. 2010; 14: 95-108
9. Odetola TD, Ekpo Nigerian Women's perceptions about human papilloma virus immunizations. J Health Educ Community Med. 2012; 2: 191.
10. Ezenwa BN, Balogun MR, Okafor Mothers' human papilloma virus knowledge and willingness to vaccinate their adolescent daughters in Lagos Nigeria. Int J Womens Health. 2013; 5: 371-377
11. Umeh BI, Nduka SO, Ekwunife Mother’s willingness to pay for HPV vaccines in Anambra state Nigeria a cross sectional contingent valuation study. Cost effectiveness and resource allocation. 2016.
12. Campos NG, Sharma M, Clark A, Lee K, Geng F, Regan C, et al. The health and economic impact of scaling cervical cancer prevention in 50 low-and lower-middle-income countries. Int J Gynaecol 2017; 138: 47-56.
13. Countries eligible for support- Gavi. The Vaccine
14. Gavi country fact sheet: Nigeria- Gavi, the vaccine