Study area and study period

The research was conducted at selected Jimma town primary and secondary schools from December 2022 to May 2023. Both public and private schools were considered. According to the 2007 census, it has a population of 120,960, of which 60,136 were women. Besides, it has 35 public primary and secondary schools and also, 37 private primary and secondary schools. Jimma is the largest city in southwestern Oromia and is located 352 kms to the southwest of Addis Ababa.

Study design

A cross-sectional study that combined quantitative and qualitative methods was carried out. A qualitative inquiry was used in-depth interviews to explain reasons provided via free text responses to describe perspectives about the Human Papillomavirus, vaccination hesitancy, and its associated factors in Jimma town school girl parents. An institution-based analytical cross-sectional quantitative study design was used to investigate associations between reasons categories and socio demographic variables of special interest in Jimma town school girls.

Study population and study unit

The sample populations: Selected Female students who were attending schools during the study period at Jimma town.

The study units: all female students who registered at the chosen institution.

Inclusion and exclusion criteria

Inclusion criteria: During the time of data collection, all female students who attended the chosen school.

Exclusion criteria: This study excluded female schoolgirls who were eligible for the HPV vaccine but did not obtain parental or caregiver consent.

Ethical considerations and procedures

During the study, basic ethical research concepts such as informed consent, confidentiality, beneficence, non-malfeasance, and justice were all taken into consideration. The ethical review committee of the AAU received this study for approval. Jimma Town Schools were contacted to acquire formal approval to undertake research activities at the selected schools. Each participant was needed to give written informed consent after the researcher explained the study’s nature, purpose, and methodology. Each participant signed the willingness confirmation after getting their approval. All study participants have been informed that the data will be treated as private and confidential and will only be used for research purposes. The participants were also made aware of their right to decline or leave at any time if they felt uncomfortable.

Sampling procedure

According to Jimma Town Municipality, there are 13 urban kebele in Jimma Town. Besides, based on Jimma Town’s educational buero, there were 33 primary and 4 sary private schools, as well as 26 primary and 9 sary public schools. In these schools, there are 2689 female public primary (grades 7–8) and 542 sary students, as well as 792 female private elementary (grades 7–8) and 103 sary students. Four primary and two secondary public schools, as well as five primary and two secondary private schools, have been selected, a total of 13 schools were selected one from each kebele, using the lottery technique. The sample size for each selected school was set proportionally based on the number of female students in the school. Each participant female school student was picked at random from selected schools through a systematic random sampling procedure.

Sample size determination

The single population proportion calculation was applied with an assumption to determine the number of female students to be included in the study. For Human Papillomavirus Vaccine Hesitancy Drives Low Coverage in Girls Attending Public Schools, the proportion was 67.1% in South Africa [19]. A single population proportion calculation based on the following assumptions: 95% confidence interval, 5% margin of error, and participant sample size were calculated as follows;

$$\begin n = Z_}^ \frac}, \end$$

where

The usual normal value \(Z_}\) = corresponds to the acceptable level of confidence.

d denotes the precision error.

P denotes an attribute’s estimated proportion.

$$\begin n&= 1.96^ \frac}\\&= 339. \end$$

After controlling for a 10% non-response rate, a sample size of 373 individuals was chosen for the study.

Variables of the study

Dependent variables: Hesitancy of HPV

Independent variables: Socio-demographic variables such as Age, Religion, Student School Grade, parents’ Educational status, Parents’ occupation, Having older sister/older sister vaccinated, Participating in school mini-media club, Ownership of mobile phone, and School type (private/public). Awareness about HPV vaccine, Attitude towards the vaccine, Rumors, and vaccination history were considered. Besides, 5C Psychological Antecedents: Confidence, Complacency, Constraints, Calculation, and Collective responsibility

Operational definitions

Human papilloma virus (HPV): A type of virus that can cause abnormal tissue growth (for example, warts) and other changes to cells. Infection for a long time with certain types of human papillomavirus can cause cervical cancer [20]. Human papilloma virus (HPV) Vaccine: a vaccination that aids in defending the body against contracting specific HPV types. Human papillomavirus vaccines are being used to prevent some of these cancers. They are also being used to prevent genital warts and abnormal lesions that may lead to some of these cancers. Also called the HPV vaccine [21]. Human papilloma virus (HPV) Vaccine Hesitancy: Delay in acceptance or refusal of HPV vaccines despite availability of vaccine services [22]. Attitude: Respondents’ attitudes toward HPV infection and vaccines were categorized as follows: negative if they had not answered correctly, and positive if they answered correctly. 5C Model: Five psychological antecedents of vaccination behavior represented in the 5C Model that measures vaccine hesitancy: confidence, complacency, constraints, calculation, and collective responsibility [23].

Data collection procedure and techniques

A structured, pre-tested interviewer-administered questionnaire and semi-structured in-depth interview guide were prepared. The questionnaire was adapted from different studies done elsewhere [13]. To ensure consistency, the interview questionnaire for the female student was first translated into two native languages (Amharic and Afan Oromo) and back to English to check for its consistency. Data collectors were three college health students and there was one public health supervisor. The following techniques were used to collect data; For quantitative data to answer objectives one and two, which are to assess the level of hesitancy and associated factors related to HPV vaccine hesitancy, the questionnaire was divided into sections that were created to evaluate socio-demographic factors, parents socio-economic status, sources of information about HPV vaccination, vaccination history, opinion and attitude toward the HPV vaccine, and HPV vaccine hesitancy. The 5C psychological antecedents of vaccination data were collected using interview-administered questionnaires.

Data quality assurance

To ensure data quality, the following operations were carried out: modifying questions from Standard tools and translating them into Amharic and Afaan Oromo. Data collectors were trained on how to use kobo tools, sampling procedures, interview tactics, and data collection processes, all while being overseen by a public health officer. The questionnaire was subjected to pre-testing to determine whether the questions were clear and suitable for extracting the necessary information and checking the understand-ability flow and consistency by taking 5% of samples from other schools which are not included in the actual data collection to evaluate the instrument’s ease of use. As a result, potential changes or modifications were evaluated at the time of data collection, and minor corrections on a few questions were included. The filled formats by the Kobo tool were checked.

Data processing and analysis

The questionnaire’s consistency and completeness were examined. After data collection was made on Kobo Tool, download it in XLS format and export it to SPSS version 20 statistical software for cleaning and checking missing data. Analysis was made using Stata version 17 statistical software. After exporting the prepared data, descriptive statistics such as frequency distribution and measures of central tendency and variability were computed to describe the major variables of the study, while frequencies and proportions were computed for categorical variables. Bivariate analyses were used to analyze the initial crude relationship between each independent variable and dependent variable through the chi-square test. The significant independent variables with a P value of 0.25 were then transferred to multivariable analysis to control for confounders. The criteria for statistical significance were a P-value of 0.05, and AOR with a 95% confidence interval was used to illustrate the strength of the relationship.