Study design

The study employed an exploratory qualitative research design using key informant interviews (KIIs) and focus group discussions (FGDs) to explore gaps and barriers preventing sustained delivery of HPV vaccination in Kaduna, Kano, and Lagos states, Nigeria. Data collection was conducted between April 2025 and October 2025 among key stakeholders involved in HPV vaccination implementation, and data transcription and analysis were completed following the end of data collection.

Study conceptual and exploratory framework

This study was guided by the WHO Health Systems Building Blocks framework, which describes health systems in 6 core interdependent components: leadership and governance, health financing, health workforce, vaccines and technologies, health information systems, and service delivery [32]. The study framework (Fig 1) assumes that governance and financing create the enabling environment through policy formulation and regulatory oversight, strategic direction-setting, and accountability and stewardship, Revenue generation, risk pooling, strategic purchasing, and providing financial protection. This action is intended to guarantee adequacy of workforce (human resource for health; HRH), commodities, and information systems, which ensures operational readiness and performance. The availability of the 3 critical components should guarantee quality service delivery that translate into effective vaccination coverage. Improved coverage drives the country to achieving the 90-70-90 goal and indication for better health outcomes. The collection and use of routine data enables feedback loops that inform adaptive policy and implementation adjustments for efficiency in service delivery and better health outcomes.

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Fig 1. Study conceptual and exploratory framework.

Adapted from the WHO Health Systems Building Blocks (WHO, 2010).

https://doi.org/10.1371/journal.pone.0350510.g001

Participant sampling and recruitment

The study employed purposive sampling to recruit key stakeholders involved in the planning, financing, delivery, and community engagement components of HPV vaccination across Kaduna, Kano, and Lagos states [33]. Eligible participants were individuals directly engaged in HPV vaccination implementation at state, local government, or community levels including policymakers, immunization officers, implementing partners, government agencies, community-based organizations (CBOs), and non-governmental organizations (NGOs).

Participants were identified during initial state-level engagements conducted as part of HPV vaccination programme activities in each state. These engagements facilitated the identification of individuals with relevant technical, operational, and community-level experience. Potential participants were approached directly and invited to participate in either key informant interviews (KIIs) and focus group discussions (FGDs) based on their roles, expertise, and availability.

A total of 55 stakeholders participated in the study across Kaduna (n = 19), Kano (n = 14), and Lagos (n = 22) States (breakdown as seen in Table 1). Participants were recruited through purposive sampling to ensure representation of key actors involved in HPV vaccine implementation. Thirty-eight (38) KIIs were conducted with policymakers (n = 6), immunization programme managers (n = 3), CBO/NGO representatives (n = 9), government agency representatives (n = 8), and implementing partners (n = 12). In addition, three FGDs were conducted with immunization officers, comprising 6 participants in Kaduna, 4 in Kano and 7 participants in Lagos (n = 17). The inclusion of stakeholders from multiple implementation levels enabled exploration of a broad range of experiences and perspectives related to HPV vaccine delivery. Data collection proceeded iteratively and was concluded when sufficient information power was achieved across stakeholder categories and study settings.

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Table 1. Breakdown of participants by stakeholder categories.

https://doi.org/10.1371/journal.pone.0350510.t001

Study setting and context

The study was conducted in Kaduna, Kano, and Lagos states of Nigeria. These states were purposively selected to reflect geographic, socio-cultural, and health system diversity relevant to HPV vaccine implementation across Nigeria. Kaduna and Kano are located in the northwestern region, while Lagos is situated in the Southwestern region of the country, allowing exploration of contextual differences across regions with varying demographic profiles, health service delivery structures, and sociocultural norms.

Kaduna State is one of Nigeria’s largest states, comprising 23 local government areas (LGAs), with a mix of urban and rural communities. Kano State is one of the most populous states in Nigeria and has experienced rapid urban growth, which presents both opportunities and challenges for large-scale immunization delivery [34,35].

Lagos State is Nigeria’s most populous and urbanized state, with an estimated population of approximately 26 million as of 2019 and high population mobility [36]. Projections suggest continued population expansion, further increasing pressure on health service delivery systems [37]. Lagos also has a high concentration of health facilities, including routine immunization centres, providing a contrasting implementation context to predominantly northern settings.

These three states were also selected because they were actively implementing HPV vaccination during the study period, providing an opportunity to examine operational, systemic, and community-level factors influencing HPV vaccine delivery across diverse implementation contexts.

Data collection procedure

Data collection was conducted using key informant interviews (KIIs) and focus group discussions (FGDs) to obtain in-depth perspectives from stakeholders involved in HPV vaccination implementation across Kaduna, Kano, and Lagos states. Data collection took place between April 2025 and October 2025 and was conducted by trained members of the research team with experience in qualitative data collection. Participant recruitment commenced on 16/04/2025 and ended on 03/06/2025.

Semi-structured interview guides were developed to guide both KIIs and FGDs (Appendix II). The guides were structured around seven thematic areas relevant to HPV vaccine implementation: policy and strategic planning, financing and financial management, vaccine and supply chain management, service delivery, demand generation and mobilization, data management and use for decision-making, and human resources for health. The guides were used flexibly to allow participants to elaborate on issues most relevant to their roles and experiences.

KIIs were conducted with individuals in leadership, policy, or technical roles who possessed in-depth knowledge of HPV vaccination planning and implementation. Focus group discussions were conducted with participants whose roles involved operational or community-level engagement, enabling shared reflection on implementation experiences and challenges.

All interviews and FGDs were audio-recorded with participants’ consent and supported by debrief notes taken by the research team. These debrief notes informed preliminary reflections and were used alongside interview transcripts during analysis.

Data collection continued until thematic saturation was reached, defined as the point at which no new codes or themes emerged from successive KIIs and FGDs.

Data management and analysis

All the audio-recordings from the KIIs and FGDs were transcribed verbatim, and cleaned to ensure accuracy and completeness, which was managed on a roll-in basis to ensure thematic saturation. Saturation was assessed iteratively by the research team using a Miro board after every five KIIs and the FGDs, with a final review confirming that the last two KIIs from each state did not produce any new information relevant to the study objectives. As an initial step, the research team conducted a rapid review of debrief notes on the Miro board to capture emerging issues and early insights, which informed preliminary thematic organization.

Codebook was developed deductively based on the seven thematic domains (policy and strategic planning, financing and financial management, vaccine and supply chain management, service delivery, demand generation and mobilization, data management and use, and human resources for health) derived from the interview guides. Four researchers (EOA, EA, OR, GH) independently coded the first three transcripts (one per state) to ensure consistency in code application (grounded theory approach). The team then convened to compare outputs, resolve discrepancies through consensus, and refine the codebook. Subsequently, all remaining transcripts were double-coded by rotating pairs from the research team (EOA, EA, OR, GH), with disagreements resolved by a third reviewer (RI). The team held regular team debriefings to maintain coding consistency and address emerging analytical issues. While inter-coder reliability was not quantified formally, the study applied a consensus-based approach throughout the process to ensure alignment. NVivo 14 software [38]was used to manage the coding process and facilitate theme development.

Following coding, a team-based inductive thematic analysis was conducted. This involved iterative reading of transcripts to identify patterns, relationships, and recurring ideas within and across the predefined thematic domains. Affinity diagramming using Miro board (an online collaborative whiteboarding platform or visual workspace for innovation) was used to cluster related codes into higher-order categories and refine overarching themes, ensuring that findings captured diverse perspectives across stakeholder groups.

Comparative analysis was conducted across states (Kaduna, Kano, and Lagos) and stakeholder categories to identify convergences and contextual variations. Key discrepancies and unique findings were further examined during validation workshops with stakeholders, which served to verify interpretations, enhance credibility, and generate additional insights incorporated into the final analysis.

Validation workshops

Validation workshops were conducted in Lagos, Kano, and Kaduna states following preliminary data analysis to present emerging findings, clarify interpretations, and generate additional perspectives that may not have been captured during the key informant interviews and focus group discussions.

The workshops included presentations of preliminary findings, breakout group discussions, and plenary feedback sessions with participating stakeholders. These sessions facilitated active stakeholder engagement and provided an opportunity to reflect on similarities and differences across states and stakeholder groups.

Feedback from the validation workshops was used to verify findings, clarify contextual nuances, and refine thematic interpretations, thereby strengthening the credibility and trustworthiness of the study results.

Ethical considerations

The study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki for research involving human participants. Ethical approval was obtained from the National Health Research Ethics Committee of Nigeria (NHREC), which reviewed and approved the study protocol and informed consent forms provided in English. The NHREC approval number is NHREC/01/01/2007-04/04/2025. The study was conducted in strict compliance with ethical standards for research involving human participants, including data collection.

All stakeholders were provided with adequate information about the study prior to giving written informed consent. Respondents were required to sign a consent form explicitly indicating their agreement to participate in key informant interviews and focus group discussions, as well as the use of insights for dissemination to relevant stakeholders. Participation was voluntary, and stakeholders were informed that they could withdraw at any time without repercussion. The study included only adult participants, and no financial incentives were provided.

Interview and focus group discussion transcripts were anonymized using codes indicating state and respondent type (e.g., IP, PM), and all data were stored securely with access restricted to authorized members of the research team. These measures ensured that the rights, privacy, and dignity of participants were respected throughout the study.

Policy and strategic planning

In the area of policy and strategic planning, the analysis revealed fragmented frameworks that often led to inconsistent implementation. The adoption of the national strategic document for HPV vaccination was not contextualized to the state realities, and the mechanism for ensuring programmatic accountability remained weak, resulting in difficulty in translating policy into effective action (Table 2).

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Table 2. Findings from affinity mapping by thematic areas and states.

https://doi.org/10.1371/journal.pone.0350510.t002

Findings across the three states revealed an absence of state-specific HPV vaccination policies, with all states relying exclusively on national guidelines. One of the policymakers (PM) explained:

“We do not actually have a state-specific policy. We are riding on the existing national policies… routine immunisation from birth to toddlers, and now the introduction of HPV vaccination.”

Participants also identified gaps within the national policy that may affect the long-term sustainability of the HPV programme. A key concern was that HPV vaccination targets girls aged 9–14 years, unlike routine immunisation, which focuses on children under two years who are easier to reach through established facility-based services and are not gender-specific. Targeting older girls presents distinct challenges, as many are in school and require both parental consent and school approval for vaccination. Although the Federal Government, in collaboration with the NPHCDA and NICRAT, has integrated HPV vaccination into the school health programme [23], implementation barriers persist. Some parents refuse vaccination, perceiving their daughters as too young or “fragile” for a vaccine associated with a sexually transmitted infection. The exclusion of boys from the programme was also viewed as potentially fuelling suspicion. Additionally, concerns were raised about vaccinating girls who may already be sexually active. One participant from the implementers noted:

“Unlike the routine vaccines We are used to, which are normally given to children below the age of two, the HPV vaccine targets older age groups not in the RI age group.”

Another policymaker highlighted additional policy-related challenges:

“One of the major gaps was the issue of the age range. Then also, another gap was that teachers themselves didn’t understand what the vaccine was all about.”

Some policymakers suggested that revising national guidelines to include boys could help increase acceptance and uptake of the vaccine. As one participant stated:

“Maybe if we expand the population a bit, maybe if we include other people, like boys, that suspicious thing will hopefully fizzle out… Community engagement could have done better.”

However, not all participants perceived these issues as policy gaps. One policymaker emphasized that the challenges were primarily implementation-related:

“It’s more of an implementation issue, not a policy gap. A lot of work has to be done around community awareness, mobilization, and advocacy to high-level personalities to bring everyone on board.”

Financing and financial management

The affinity mapping highlighted that the budget allocation for HPV vaccination was rather insufficient, with significant delays in fund disbursement and weak accountability mechanisms. These issues disrupt program implementation and limit the ability to plan and implement long-term strategies. There was also the concern about sustainability associated with heavy reliance on donor funding (Table 2).

Across all three states, financing for HPV vaccination activities including community awareness and service delivery is largely supported by implementing partners and the National Primary Health Care Development Agency (NPHCDA), with minimal direct state government funding.

An immunization officer explained that funding for the programme is currently driven by external support:

“A large portion of the funding for HPV vaccination comes from partner support. Funding operates under an ‘envelope system’ at the primary health care board.”

Similarly, a policymaker emphasized the reliance on development partners, noting that state contributions mainly cover logistics and personnel:

“We depend a lot on international partners… development partners. The state also partly funds implementation by providing logistical support and human resources.”

A major financing gap identified across states is the absence of a dedicated budget line for HPV vaccination. As one policymaker stated:

“There is no specific, dedicated budget line for routine immunization, which includes HPV vaccination, in the state’s budget.”

This dependence on donors is further illustrated by another respondent who explained that states often rely on partner-driven outreach:

“We are leveraging for outreach by other partners. When they come, they come and support us.”

Delayed fund disbursement and unclear financial flows were also highlighted as challenges that weaken financial management and compromise effective programme implementation.

Given these gaps, stakeholders recommended the establishment of dedicated HPV budget lines within state budgets, increased government financial commitment to reduce donor dependence, and strengthened financial transparency, combined with timely disbursement mechanisms to support sustainability.

Vaccine supply chain management

From the affinity mapping (Table 2), the issues with the vaccine supply chain management stemmed from frequent stockouts due to poor forecasting and distribution. Inadequate storage facilities at local levels and logistical challenges associated with the last-mile delivery directly affected vaccination efforts at target locations.

Vaccine delivery across the three states is constrained by multiple supply chain challenges, including incomplete vaccine kits, frequent stock-outs in high-demand locations, and inadequate cold chain capacity. These issues are compounded by poor coordination and unpredictable demand patterns, which limit the efficiency of vaccine distribution. An implementing partner described the inequitable distribution:

“Yes… supply is not equitable. In areas with high demand, they run out, while in areas without demand creation, vaccines there are unused.”

Stakeholders emphasized the need for stronger logistics systems to ensure consistent vaccine availability.

As one implementing partner explained:

“Accurate data collection and microplanning, strengthening monitoring and evaluation, logistics and financial support, and improved technology and capacity building for data management.”

Key recommendations included improving cold chain infrastructure, enhancing microplanning, and adopting real-time stock monitoring systems. Consistent funding for supply chain activities was also highlighted as essential for uninterrupted vaccine delivery.

Human resources for health

From the analysis, stakeholders noted shortages of trained personnel, particularly at the community level. There was also the issue of unequitable distribution of health workers across regions, with inadequate incentives for healthcare workers’ retention (Table 2).

Across all three states, respondents consistently reported significant shortages of human resources for health, particularly in rural areas where a single health worker is often responsible for delivering multiple services. A CBO representative emphasized the extent of the gap:

“Human resources is a major problem. We don’t have enough trained personnel on HPV.”

The HPV vaccination programme also relies heavily on temporary or ad hoc staff, many of whom are poorly compensated, insufficiently trained, and frequently overworked. This situation contributes to burnout and low motivation among frontline workers. An implementing partner highlighted these challenges:

“Many health workers are temporary staff who are not paid living wages. They are overworked, leading to pockets of burnout and low motivation.”

Participants further noted the absence of structured HPV-specific training or refresher courses, which limits the capacity of health workers to deliver high-quality services.

To address these gaps, stakeholders recommended recruiting and retaining more skilled health workers in underserved areas, institutionalizing regular HPV-focused training and refresher programmes, and introducing incentives to improve the motivation and performance of temporary staff.

Data management and data for decision making

From the affinity mapping (Table 2), data management and decision-making emerged as another significant barrier. While the systems both state-specific or national were optimized to provide real-time and reliable data for routine immunisations, there was no adaptability for HPV vaccination campaigns, which hindered the ability to guide interventions effectively. There was also limited capacity for analysis and use in planning, which in turn weakens the evidence base for decision-making and reduces the responsiveness of programs.

Across the three states, District Health Information System2 (DHIS2) serves as the primary platform for data management, supported by local government–level registers, tally sheets, and Open Data Kit (ODK) tools. These data are eventually uploaded into DHIS2. However, the system faces persistent operational challenges, including server downtime, poor network connectivity, unreliable power supply, and the absence of digital data entry systems in many rural LGAs. Data discrepancies were particularly noted as a significant issue in Kaduna State. An implementing partner explained:

“Yes… data discrepancies, number of doses not tallying with girls vaccinated. Some facilities do not have that accountability to give you the data that you want.”

Another challenge is the incomplete integration of HPV indicators into routine immunization reporting tools. An immunization officer illustrated this gap:

“Previously, standard registers, tally sheets, and summaries did not have dedicated columns for HPV vaccination. Healthcare workers improvised by drawing a margin line and writing ‘HPV’ in the comment section.”

Stakeholders emphasized the need to strengthen monitoring and evaluation systems, fully integrate HPV indicators into routine immunization tools, provide digital devices and data management training for health workers, and improve infrastructure for data reporting, particularly in rural areas.

Demand generation and social mobilization

Demand generation and social mobilisation were also constrained by poor community engagement and trust-building. This was compounded by cultural and religious beliefs that antagonize HPV vaccination. There were also ineffective communication strategies that were not adequately tailored to the diverse populations in the three states. As a result, efforts to mobilize communities were often met with resistance or limited uptake (Table 2).

Persistent misinformation continues to undermine HPV vaccine uptake across the three states. Common misconceptions include claims that the vaccine causes infertility, is a form of secret family planning, or encourages promiscuity among young girls. One implementing partner highlighted these concerns:

“Association of HPV with family planning, fear of sterilization, and belief that girls are too young for sexual health topics.”

Another respondent noted that misinformation is particularly prevalent in northern Nigeria, where distrust of vaccines remains high:

“In the Northern part of Nigeria… misconceptions about vaccine safety and effectiveness. COVID-19 vaccine rumours may also affect HPV uptake. The use of gestures and influencers is helpful.”

Cultural and religious resistance, combined with irregular and unsustained awareness campaigns, further weakens demand for the vaccine. A CBO representative explained:

“Some communities resist due to traditional beliefs or religious reasons. Some believe there’s no need because they’ve ‘always been fine.’”

Participants emphasized that trusted community messengers such as religious leaders, traditional rulers, teachers, and civil society organizations play a central role in shaping community perceptions. As one respondent stated:

“They play a major role… we should start from them. Pastors and community influencers can shift perceptions and drive uptake.”

To address these demand-side barriers, stakeholders recommended leveraging influential community leaders, delivering consistent and culturally appropriate awareness campaigns in local languages, and sharing survivor stories to counter misinformation, build trust, and strengthen vaccine acceptance.

Service delivery

The affinity mapping showed that the quality of service delivery was inconsistent, particularly with the outreach sessions that targeted the hard-to-reach communities. There were also infrastructure challenges that affected cold chain maintenance, which further compromised the reliability of services (Table 2).

Although HPV vaccination has been integrated into routine immunization services, delivery remains constrained by multiple operational and community-level barriers. Key challenges include shortages of human resources for health (HRH), limited outreach capacity, and persistent socio-cultural resistance. Participants explained that outreach teams are often unable to reach underserved communities, and service access is further restricted by costs in private health facilities.

Several barriers were identified at health facilities, schools, and within communities, including rumours linking the vaccine to infertility, resistance from school authorities and parents, security concerns, and health worker shortages. One community-based organization (CBO) representative highlighted the impact of misinformation:

“The barriers we majorly face are from the teachers, LGAs, and communities. Rumours that the HPV vaccine causes infertility.”

Another CBO respondent described additional social and structural barriers:

“There are cultural and social barriers… It starts with churches and mosques, then traditional leaders. Also, because of the JAPA syndrome, healthcare workers are overwhelmed… limited access in rural areas… private facilities aren’t involved enough.”

Participants also noted disparities in service delivery between urban and rural areas, highlighting the need for tailored strategies to reach hard-to-reach communities.

Overall, improving service delivery will require expanded targeted outreach to marginalized girls, strengthening the capacity of health workers for integrated service delivery, engaging school and community leadership structures, and addressing financial barriers particularly in private facilities to promote equitable access to HPV vaccination.