Associations of socioeconomic factors with parents' awareness and acceptability of HPV vaccination in sub-Saharan Africa - a systematic review and meta-analysis.

BACKGROUND: Despite the effectiveness of Human Papillomavirus (HPV) vaccines in preventing cervical cancer, the low coverage of the vaccine remains a significant challenge, particularly in Sub-Saharan Africa, where the disease burden is high, and access to preventive services is limited. Socioeconomic determinants play a central role in shaping health behaviors and health outcomes. The uptake of the HPV vaccine is partly determined by parental decision-making, and this review aimed to examine whether socioeconomic factors are associated with awareness and acceptability of HPV vaccination among parents in sub-Saharan Africa. METHODS: A systematic literature review was carried out according to the Preferred Reporting Items for Systemic Reviews and Meta-analysis guidelines. The databases searched included Medline, Embase, Web of Science, and the Cochrane Library. Three independent reviewers conducted the screening, study selection, data extraction and risk of bias assessment. Meta-analyses were performed and the certainty of evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation. RESULTS: The review included 26 articles, comprising 24 cross-sectional and two cohort studies. Seven studies examined parental awareness, 14 studies examined parental acceptability, and four studies examined both outcomes. Parents' awareness of the HPV vaccine was associated with higher levels of education (OR = 3.81, 95% CI: 2.11-6.88, I2 = 84%, four studies), higher income (OR = 1.96, 95% CI: 0.72-5.29, I2 = 89%, four studies), moderate income (OR = 1.22, 95% CI: 0.67-2.23, I2 = 74%, four studies). Parents' acceptance of HPV vaccination was associated with higher levels of education (OR = 2.06, 95% CI: 1.35-3.15, I2 = 77%, seven studies), higher income (OR = 2.16, 95% CI: 1.21-3.84, I2 = 77%, five studies), moderate income (OR = 1.33, 95% CI: 0.86-2.07, I2 = 74%, five studies) and urban residence (OR = 1.28, 95% CI: 0.84-1.96, I2 = 64%, five studies). The certainty of evidence ranged from low to very low. CONCLUSIONS: There may be a positive association between socioeconomic status, especially higher education and higher income, and parental awareness and acceptance of HPV vaccination. However the evidence is currently limited and inconsistent.