Defining and validating an HPV vaccination motivation score in Kenya and Malawi: A tool for use in low- and middle-income countries.
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BACKGROUND: Studies have evaluated reasons for low HPV vaccine uptake globally but use instruments that were validated only in high-income countries. Our objectives were to (1) determine factors associated with vaccination against human papillomavirus (HPV) in two low- and middle-income countries; and (2) use them to develop and validate a simple score to measure motivation to vaccinate one's daughter against HPV. METHODS: We undertook 3 rounds of data collection: Kenya 2022 (1345 parents/guardians of girls aged 10-16 years, via nationwide mobile phone random-digit dialing), Malawi 2022 (288 parents/guardians of girls aged 9-13 years, via household surveys in three communities), and Kenya 2024 (re-survey of 678 Kenya 2022 respondents who reported having no vaccinated daughters in 2022). The survey included items from the Vaccine Hesitancy Scale-Child and Vaccine Hesitancy Scale-HPV, the Human Papillomavirus Attitudes and Beliefs Scale, and the Wellcome Global Monitor, and parent-reported HPV vaccination of eligible girl(s) in the household. RESULTS: We found four latent constructs significantly associated with vaccination status in the Kenya 2022 data: Confidence in Vaccine Benefits, Safety Concerns About the HPV Vaccine, Talks About HPV With Others, and Perceives Pro-HPV Vaccination Social Norms. We use these to create an HPV Vaccination Motivation Score; in the Malawi 2022 data (external validity), a 3-point increase in this score was associated with greater odds of having a vaccinated daughter (OR = 1.55; p < 0.0001), and in the Kenya 2024 data (predictive/temporal validity), a 3-point increase in the score was associated with significantly greater odds of vaccination in the intervening two years (OR = 1.14; p = 0.0008). CONCLUSIONS: This HPV Vaccination Motivation Score can be used to investigate factors associated with HPV vaccination in diverse global settings - and this information can be used to design more effective interventions and programs to increase vaccine coverage and improve health outcomes.