Dr Ifeanyi M. Nsofor and Drew Bernard (Guest Writers)
On October 24, 2023, Nigeria’s First Lady Oluremi Tinubu accompanied by the coordinating Minister of Health and Social Welfare, Professor Muhammad Ali Pate, launched Phase I of a nationwide Human Papilloma Vaccine (HPV) vaccination campaign across 16 states and Nigeria’s Federal Capital Territory. The goal of this nationwide campaign supported by Gavi — The Vaccine Alliance and other partners was to vaccinate 7.7 million adolescent girls against cervical cancer.
One month prior to the launch, the Behavioural Insights Lab (BiL) carried out a survey with dual objectives: to assess the acceptability of the HPV vaccine and to identify key behavioural factors influencing HPV vaccination decisions among male and female caregivers of girls aged 9–17 years across six states — Anambra, Bauchi, Lagos, Niger, Rivers, and Sokoto.
The Behavioural Insights Lab (BiL) crafted the survey by the Fogg Behaviour Model and secured approval from the National Health Research Ethics Committee (NHREC). The survey was disseminated through a virtual platform, utilising Meta’s networks — Facebook, Instagram, and Messenger — to enlist participants and gather their responses.
This is not the first time that BiL is conducting behavioural research in Nigeria. In 2022, the team used the Fogg model to design and conduct a survey to understand the ‘drivers of and barriers to COVID-19 vaccine uptake in Nigeria’. Indeed, behavioural science is increasingly being recognised as a critical component of global health programming. For instance, the World Health Organisation Technical Advisory Group on Behavioural Insights and Sciences for Health says, “changing behaviours is complex and may not happen even when life is at stake — it requires more than clinical and epidemiological expertise. To ensure a robust international instrument, our first suggestion is that you consider including the uses of behavioural and social sciences in pandemic prevention, preparedness, and response at relevant places in the international instrument”.
The Fogg Behaviour Model posits that behaviour change occurs when sufficient motivation, ability, and an effective prompt converge at the same moment. Motivation factors include anticipation (hope versus fear), belonging (social acceptance versus social rejection), and sensation (pleasure versus pain). In contrast, ability factors are time, money, mental effort, physical effort, and routine. When someone hears a radio jingle (prompt) about the benefits of healthy eating, which enhances their hope for a better future (motivation), and they have the means to purchase the necessary vegetables (ability), the convergence of these factors at the same moment can lead to the behaviour change of choosing healthier foods.
The survey encompassed questions assessing respondents’ knowledge of the HPV vaccine and cervical cancer, as well as their behaviours, motivations, abilities, social norms, and demographics. Responses were captured on a five-point scale with the options: strongly agree, agree, neutral, disagree, strongly disagree, and don’t know/can’t say.
Results
A total of 1,429 individuals participated in the survey, with Lagos contributing the highest number of respondents (454), followed by Rivers (283), and Anambra having the lowest (106). Geographically, a majority of the respondents were urban dwellers, with 56% residing in cities and 34% in towns, while only 10% were from rural areas. In terms of family roles, the respondents were diverse: 27% were mothers, another 27% were fathers, accompanied by aunts (15%) and uncles (22%) making up a significant portion of the caregiver demographic.
Regarding the geographic distribution of caregivers, 41% were from the three Northern States and 59% from the three Southern States. The majority of respondents, about 61%, were in the 30–39 age range, while 31% were 40 years or older. In terms of gender, the survey sample comprised 42% women and 56% men, with the remaining 1.6% not disclosing their gender. Notably, the respondents were highly educated: 53% held a bachelor’s degree or higher.
Insights and Implications for Practice:
Below are four key insights gleaned from the survey data. Each insight is accompanied by its practical implications, offering guidance on how to enhance HPV vaccination efforts in Nigeria. These insights not only reflect the survey findings, but also suggest actionable strategies to improve vaccine uptake among the target population.
1. Percentage of caregivers who believe that their girl child is very likely to get the HPV vaccination in the next 12 months.
A significant majority of caregivers, 60%, believe that it is very likely the girl child in their care will receive the HPV vaccine in the next 12 months. This optimism is more prevalent in the northern states (65%) compared to the southern states (57%).
Further reinforcing this positive outlook, 70% of respondents agreed with the statement ‘getting the girl who is in my care vaccinated against HPV is important to me’, indicating high motivation. Additionally, 76% disagreed with the notion that ‘getting the girl child vaccinated against HPV is difficult’, reflecting a high level of perceived ability to vaccinate.
These findings underscore the critical roles of both motivation and ability in vaccination efforts. By strategically timing and designing prompts, we can capitalise on this willingness and perceived ease, converting them into tangible vaccination actions.
2. Most of my family and friends approve of girls getting vaccinated for HPV.
The survey revealed that respondents who perceived approval from friends and family members for HPV vaccination were 1.7 times more likely to believe that their girls would be vaccinated within the next 12 months. This finding underscores the significant impact of social norms on the motivation to vaccinate girls against HPV in Nigeria. Campaigns aimed at normalising vaccination could therefore substantially increase the number of caregivers willing to vaccinate girls in their care.
Furthermore, active discussions about the vaccine within social networks are shown to greatly boost the likelihood of caregivers vaccinating their adolescent girls.
3. How likely are you to discuss HPV vaccination with family or friends?
Caregivers who were very likely to talk about the HPV vaccination for their girls with family and friends were 4.8 times more likely to believe that their girls would be vaccinated within the next 12 months. This emphasises the power of social conversations in encouraging vaccine uptake. Social networks and community dialogues are key in spreading information and shaping attitudes towards health practices like vaccination.
4. Getting vaccinated against HPV will help girls have a better future and allow girls to have a more fulfilling life.
When it comes to motivating caregivers, no other motivational factors come close to these two factors. Caregivers perceiving the HPV vaccine as a path to a more promising future for their girls are at least 30% more likely, in all scenarios, to pursue vaccination. This highlights the significant influence of optimism and ambition on such a crucial health choice. By focusing on the vaccine’s role in enabling a better and more fulfilling future, campaigns can tap into a powerful emotional driver for caregivers, leading to increased vaccination rates.
As of November 30, 2023, a remarkable milestone was reached in Nigeria’s public health efforts: over 4.6 million girls received the HPV vaccine, as reported by Muyi Aina, Executive Director of the National Primary Health Care Development Agency (NPHCDA). This significant achievement, representing nearly 60% of the target population, corroborates the Behavioural Insights Lab’s findings and signals Nigeria’s steady progress toward the goal of 7.7 million vaccinations.
In preparation for the second phase of Nigeria’s HPV vaccination campaign, the Behavioural Insights Lab is set to conduct a follow-up survey. With Nigerian caregivers showing high motivation for vaccinating the girl-child, it’s crucial to continue providing health workers with these behavioural insights. Such support is key to ensuring a brighter and healthier future for the girl-child in Nigeria.
About the authors
Ifeanyi M. Nsofor is a public health physician and behavioural science researcher. He is the Principal Investigator of the Nigeria HPV survey.
Drew Bernard is a digital communications leader who has been helping the social sector use new media to drive measurable change for more than two decades.