Bridging the Gap: Disparities in HPV Vaccine Uptake Between In-School and Out-of-School Girls Following a Demand Generation Intervention in Ethiopia: A Cross-Sectional Study

Background: Despite the availability of safe vaccines, Ethiopia’s human papillomavirus (HPV) vaccine uptake remains suboptimal, particularly among out-of-school girls (OOSGs). This study examines the effect of multi-channel demand generation messages in two districts to determine which interventions most effectively improve uptake. Methods: A convergent mixed-methods design was employed across four districts in the Somali and South Ethiopia regions, with Jigjiga and Derashe serving as intervention sites and Gode and Kolango Zuria as controls. For the quantitative component, 950 sample households were recruited using cluster sampling. The qualitative inquiry involved 27 in-depth interviews (IDIs) and 16 focus group discussions (FGDs) within the intervention sites. Results: A total of 950 caregivers and 1134 girls completed the survey. Awareness was significantly higher among caregivers (AOR: 4.42; 95% CI: (3.06, 6.39)) and girls (AOR: 7.63; 95% CI: (3.49, 16.67)) in intervention sites, as well as among in-school girls (AOR: 13.46; 95% CI: (4.09, 41.90)). The mean vaccination coverage reached 71%, with significantly higher rates in intervention sites (AOR: 4.07; 95% CI: (2.29, 7.23)) and among in-school girls (AOR: 47.16; 95% CI: (20.23, 109.9)). Interpersonal communication—via teachers, peers, community health workers and vehicle-mounted promotion—was more effective in influencing awareness, attitude and uptake. Barriers for OOSGs included limited access to vaccination sites, low campaign awareness, misconceptions and gender-related issues. Conclusions: Appropriate demand generation strategies effectively enhance HPV awareness and vaccine uptake, yet a significant equity gap remains, as only one-third of OOSGs received the vaccine compared with 85% of in-school girls. Targeted interventions are recommended for OOSGs focused on both access to service and context-specific demand creation to address this disparity.