Multi-sectoral engagement to improve human papillomavirus vaccination uptake in a conflict-affected district of Cameroon

¹Expanded Program on Immunization, Ministry of Public Health, South West, Cameroon, ²Expanded Program on Immunization, Central Technical Group, Ministry of Public Health, Buea, Cameroon, ³District Health Service, Buea, Cameroon, ⁴UNICEF Regional Office, North West and South West, Buea, Cameroon

^&Corresponding author
Martha Ndiko Ngoe, Expanded Program on Immunization, Ministry of Public Health, South West, Cameroon

Introduction    

Human papillomavirus (HPV) is the most prevalent sexually transmitted infection worldwide and a major contributor to cancers of the cervix, penis, anus, and oropharynx. Globally, HPV is estimated to account for roughly 5% of all cancers, with types 16 and 18 responsible for about 70% of cervical cancer cases [1,2]. Cervical cancer is the fourth most common cancer among women globally and disproportionately affects women in low- and middle-income countries (LMICs), where screening, early treatment services, and access to timely vaccination are limited [2-4].

In Cameroon, despite the availability of HPV vaccination free of charge since 2020 and its integration into the Expanded Program on Immunization (EPI) targeting nine-year-old girls, uptake has remained suboptimal. Multiple regions report annual coverage below 50%, particularly in areas facing humanitarian challenges [3,4]. Barriers include low awareness, rumors linking HPV vaccination to infertility, limited engagement of trusted community influencers, and disruptions caused by the ongoing sociopolitical crisis in the Anglophone regions [5-8].

Evidence from Cameroon and similar contexts suggests that biomedical availability must be paired with culturally appropriate engagement and trust-building. For instance, HPV demonstration projects by the Cameroon Baptist Convention Health Services achieved high uptake through robust community sensitization despite user fees [5]. Knowledge and attitudes among health workers and parents also shape uptake: nurses' knowledge regarding HPV and vaccines has been variable in Cameroon [6], and qualitative work in the North-West Region shows that parental awareness and beliefs strongly influence decision-making [7]. Beyond Cameroon, studies in South Africa have reported that women's beliefs and maternal-child communication about sexual health affect willingness to vaccinate [8].

Against this backdrop, the Buea Health District in the South-West Region faces additional barriers related to displacement, intermittent school closures (in some health areas), and disrupted health services. We therefore designed a multi-sectoral engagement model-drawing on schools, religious institutions, community leaders, and local media, to address rumors, increase trust, and reduce access barriers. A key innovation in this intervention was the inclusion of adolescent boys, authorized by the Ministry of Public Health based on National Immunization Technical Advisory Group (NITAG) guidance, both to directly protect boys against HPV-related disease and to mitigate gender-specific rumors, particularly those linking the vaccine to female infertility. The model was implemented through two rounds of mini-campaigns in late 2024 and mid-2025. This paper details the strategies used, coverage achieved, and lessons learned, and positions the findings within Cameroonian and regional evidence to inform policy and program decisions, especially in conflict-affected regions (Figure 1, Figure 2).

Methods     

Study design and setting: a district-level interventional study in the Buea Health District, South-West Cameroon. The district comprises seven health areas (Bova, Bokwango, Buea Road, Molyko, Muea, Tole, and Likoko) with heterogeneous security conditions and school attendance patterns due to the ongoing crisis. Two rounds of HPV vaccination mini-campaigns were implemented: Round One from November 1 to 3, 2024, and Round Two from July 18 to 21, 2025.

Target population: adolescent girls aged 9-14 years and boys aged 9-10 years were eligible. The national routine policy prioritizes both nine-year-old girls and boys, guided by the country's NITAG and authorized by the Ministry of Public Health.

Delivery strategies: three complementary delivery approaches were used.

(1) School-based vaccination: health teams were deployed to primary and secondary schools after prior notification through head teachers and Parent-Teacher Associations (PTAs). Consent forms and information leaflets were distributed, and teachers reinforced messages in class and during PTA meetings. Vaccination teams visited the schools and those whose parents consented were vaccinated.

(2) Community-based sessions: fixed or temporary posts were set up in churches, community halls, markets and other popular spots in the community. Religious leaders made announcements during services, addressed questions, and encouraged families to present eligible adolescents.

(3) Door-to-door outreach: in neighborhoods with low school attendance or recent displacement, mobile teams conducted limited household visits to reach out-of-school adolescents. This approach was resource-intensive and used strategically based on micro-planning and community leader guidance.

Stakeholder engagement: prior to each round, advocacy meetings were organized with education authorities, head teachers and principals, religious leaders, and local government administrators. These sessions reviewed HPV disease burden, vaccine safety and efficacy, the local schedule, and operational plans. Teachers integrated HPV messages into assemblies and PTA fora; pastors, priests, and imams addressed rumors during sermons and endorsed vaccination publicly; community leaders mobilized households through meeting announcements and door-to-door sensitization with town criers. Local radio hosted live call-in shows with EPI staff, teachers, and faith leaders to answer questions and dispel misinformation. Vaccinators and data managers received refreshers on interpersonal communication, adverse events monitoring, and data documentation.

Data collection and analysis: daily tally sheets and vaccination registers were used to record doses administered. Data were summarized on synthesis forms, entered into a regional Excel mask, and uploaded to DHIS-2. Triangulation across tally sheets, registers, and monitoring charts was conducted to ensure completeness and resolve discrepancies. Coverage was calculated using projected target populations for each health area; however, denominators were recognized as uncertain due to internal displacement and the absence of a recent census. Descriptive statistics were used to summarize coverage by round, sex, and health area.

Ethical considerations: the intervention was implemented by the District Health Service and the Regional Delegation of Public Health as part of routine EPI activities. Only aggregated program data without personal identifiers was analyzed. Permission to use and publish program data was obtained from the Buea DHS and the South-West Regional Delegation.

Results     

Round one (November 2024): a total of 5,459 adolescents were vaccinated across the seven health areas, corresponding to 32% district coverage. The female-to-male ratio was 4.1:1, indicating that initial acceptance remained higher for girls. Coverage varied widely: Bova achieved 60% while Muea recorded 24% (Table 1).

Round two (July 2025): a total of 1,862 adolescents were vaccinated (11% district coverage). In contrast to Round One, more boys than girls were vaccinated, suggesting improving acceptance among families of boys and the influence of gender-neutral messaging. Bova again recorded the highest coverage (32%), while Muea remained the lowest (4.8%) (Table 2).

Stakeholder contributions: field reports and debriefings consistently identified teachers as the most influential actors in improving acceptance. Teachers reassured parents about vaccine safety, explained that HPV vaccination prevents future cancers, and organized class-by-class mobilization on vaccination days. Religious leaders explicitly tackled infertility rumors during services and endorsed vaccination as a stewardship of child health. Community leaders facilitated access in hard-to-reach quarters by guiding teams and convening community dialogues. Media call-in programs allowed parents to ask questions live and hear clarifications from health officials and respected community figures. These combined efforts were repeatedly cited by vaccination teams as critical to increased turnout compared with previous years.

Discussion     

This intervention demonstrates that multi-sectoral engagement linking schools, faith communities, local leaders, and media can improve HPV vaccination uptake in a district with historically low performance and substantial operational constraints [8,9]. Although overall coverage remained below national and global targets, the magnitude of turnout relative to previous periods, and the consistency of Bova's higher performance, suggest that context-tailored engagement can unlock demand even amid insecurity.

The inclusion of boys was a pivotal adaptation. Framing HPV vaccination as cancer prevention for all adolescents reduced the perception that the vaccine pertains only to female sexuality, which has been a source of stigma and rumors in many settings. Evidence from other countries supports this approach: including boys increases herd protection, directly prevents HPV-related disease in males, and can improve community acceptance of the program itself [10,11]. Within Cameroon, program experiences have begun to describe the feasibility of gender-neutral approaches and their potential to normalize HPV vaccination [12]. Our finding that more boys than girls were vaccinated in Round Two suggests that gender-neutral messaging, combined with teacher and faith-leader endorsement, helped shift household decision-making.

The observed heterogeneity across health areas highlights how local context determines the success of delivery strategies. Bova's higher coverage likely reflects strong school participation, cohesive community leadership, and better security allowing predictable school sessions. Muea's persistently low coverage may be linked to insecurity, displacement, and reduced school attendance, which limit the reach of school-based strategies. These findings underscore the need for flexible micro-planning and the selective use of door-to-door outreach and weekend sessions to reach out-of-school adolescents [13,14].

Our results align with Cameroonian evidence that trusted messengers-teachers, nurses, and religious leaders- play a decisive role in acceptance. School-based campaigns in the Saa Health District reported high uptake when teachers and priests actively endorsed vaccination and addressed concerns [9,15]. Qualitative studies in the North-West Region show parental knowledge and beliefs as central determinants of acceptance, pointing to the importance of repeated, dialogic communication [7]. Similar dynamics have been documented in South Africa and other LMICs where maternal beliefs and communication norms shape adolescent vaccination [8].

Sustainability considerations are critical. Our mini-campaigns required intensive mobilization and inter-sectoral coordination. To sustain gains, we recommend institutionalizing HPV vaccination within the school health platform with scheduled school days for vaccination each term, while maintaining standing community posts in churches and markets. Media components, particularly call-in shows featuring health workers and respected community figures-should be budgeted as a routine demand-generation line item. In addition, selective door-to-door strategies can be reserved for neighborhoods with chronically low school attendance or recent displacement.

From a policy perspective, integrating gender-neutral vaccination into routine guidance while monitoring vaccine supply and logistics could enhance both equity and acceptance. As new evidence emerges on single-dose schedules and on broader valency vaccines, Cameroon may also consider the potential added value of the 9-valent vaccine, especially given the high genotypic diversity of HPV noted among women in Cameroon [16]. Demand-generation and supply-side measures should evolve together to achieve the World Health Organization's cervical cancer elimination targets [17].

Finally, this intervention adds to regional evidence that conflict-affected and humanitarian settings can still register meaningful progress toward HPV vaccination goals when programs invest in community engagement and flexible delivery [14]. The key ingredients were not high-tech but high-trust: engagement of teachers, faith leaders, community heads, responsive radio programs, and courteous, well-briefed vaccination teams.

Limitations: this study has several limitations. First, coverage estimates relied on administrative denominators, which may be inaccurate due to the absence of a recent census and substantial internal displacement. Second, while the strategy included out-of-school adolescents through community posts and limited door-to-door visits, reach in these groups likely remained suboptimal. Third, we assessed doses delivered during campaign windows and did not measure long-term retention for newer cohorts. Fourth, we did not implement pre- and post-intervention knowledge, attitude, and practice assessments; therefore, the behavioral mechanisms by which engagement improved acceptance could not be quantified. Finally, without a comparison district or randomized design, attribution of observed changes solely to the multi-sectoral engagement package should be interpreted cautiously.

Conclusion     

Multi-sectoral engagement, centered on teachers, religious leaders, community heads, and media was associated with improved HPV vaccination uptake in the Buea Health District. Authorizing the inclusion of boys appeared to mitigate gender-specific rumors and enhance household acceptance. While coverage remains below national aspirations, the approach is feasible, context-appropriate, and ready for adaptation across other low-performing districts in the South-West Region and beyond. Institutionalizing these strategies within routine service delivery, alongside continued community dialogue and flexible outreach, could accelerate progress toward cervical cancer elimination targets.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Martha Ndiko Ngoe conceptualized the study, supervised implementation, analyzed data, and drafted the manuscript. Pamela Besong Oben, Nchanji Stanly Ngala, Laura Nini-Kumi Wantim, Nebongo Daniel Nebongo, and Sylvester Nji Toh supported field coordination, data collection, training, and manuscript revision. All authors reviewed and approved the final manuscript.

Acknowledgments     

We thank the Ministry of Public Health of Cameroon, the South-West Regional Delegation of Public Health, UNICEF, the Buea Health District, school administrators and teachers, community and religious leaders, and local media houses for collaboration and support. We appreciate the dedication of vaccinators and data managers whose efforts ensured intervention success.

Tables and figures     

Table 1: HPV vaccination coverage by health area - round one (November 2024)

Table 2: HPV vaccination coverage by health area - round two (July 2025)

Figure 1: map of Cameroon depicting the Buea Health District

Figure 2: evolution of HPV vaccination among adolescent boys and girls aged 9-13 years in the Buea Health District from 2020 to 2025

References