Generalized structural equation modeling of demographic disparities in human papillomavirus (HPV) vaccine uptake among female schoolteachers in a middle eastern country

The complex mechanisms involving knowledge and behavioural factors in causing low human papillomavirus (HPV) vaccine uptake are not yet fully understood. This study sought to disentangle direct, indirect, and total effects (DE, IDE, TE) of age, unawareness of HPV causal role in cervical cancer and family history of cervical cancer on HPV vaccine uptake among females. In a cross-sectional study, female schoolteachers employed in public and private-sector high schools were enrolled. Data were collected using a self-administered questionnaire during January 2018. Prevalence of HPV vaccine uptake was computed. The effects of age, and family history of cervical cancer through mediator (i.e. unawareness of HPV's causal role in cervical cancer) on HPV vaccine uptake were examined in a generalized structural equation modeling (GSEM) framework. Of 1,341 participants, 60% were unaware of HPV causal role in cervical cancer and 98.1% were HPV unvaccinated. The results of GSEM showed that participants had significantly higher odds of being unvaccinated if they were unaware of the causal role of HPV in cervical cancer (p = 0.001) or had no family history of cervical cancer (p < 0.001). Moreover, absence of a family history of cervical cancer had a significant (p = 0.020) indirect effect on HPV vaccine uptake. The proportion of indirect effect mediated was 61.61%. Increasing awareness about the HPV's causal role in cervical cancer, and benefits of HPV vaccine may augment the HPV vaccine uptake. If implemented, future studies may look at the impact of such efforts.