February 2025 — Cervical cancer is the leading cause of cancer-related illness and death among Zimbabwean women, primarily caused by the Human Papillomavirus (HPV). To combat this, Zimbabwe launched an HPV vaccination program in 2014 as a pilot project, expanding it nationwide in 2018 to protect girls and women from HPV-related cancers. Although vaccination coverage was high in 2018, 2019, and 2021, it dropped significantly in 2022. To explore the behavioral and social factors influencing HPV vaccine uptake, UNICEF conducted a comprehensive study.

Strategy and Implementation

UNICEF supported the Ministry of Health and Child Care in conducting a cross-sectional study in three districts: Bulawayo (metropolitan), Kwekwe (urban and rural), and Mberengwa (rural). The study used the Behavioral and Social Drivers (BeSD) framework to assess thinking and feelings, motivation, social processes, and practical issues. Data collection included interviews, focus group discussions, and self-administered questionnaires, guided by the BeSD model. A desk review of administrative databases and published documents was also conducted.

Results

• Knowledge Gaps: Approximately 30% of adolescent girls lacked knowledge about HPV, the vaccine, and cervical cancer. This lack of knowledge contributed to low risk perception and limited demand for the vaccine. Additionally, 40% of adolescents were less concerned about cervical cancer, and discussions about sexual and reproductive health, including HPV, were often neglected.

• Caregiver Influence: While caregivers had high knowledge levels about HPV, the vaccine, and cervical cancer, their participation in taking girls for vaccination was limited. Notably, 14.6% of caregivers were not concerned about HPV. Mothers increased their protective behavior once girls started menstruating, highlighting the need to engage mothers in HPV vaccination efforts.

• Vaccine Confidence: Concerns about vaccine safety, side effects, and infertility were prevalent among both adolescents and caregivers. Injection pain was a key concern for 19.55% of adolescents, while 22.94% of caregivers were worried about side effects. Despite high intentions to vaccinate, 28% of adolescents had heard negative information about the vaccine.

• Trusted Advisors: Health care workers were the primary advisors that caregivers went to for advice (87.16%), while mothers and friends were the main advisors that adolescents consulted (41.67%). Health care workers came third for adolescents, indicating a need to make the health system more conducive for them.

• Social Norms: Positive norms among caregivers, peers, family, religious leaders, and community leaders supported vaccination. However, 3.7% of caregivers and 15% of adolescents faced religious barriers to accessing HPV vaccinations. Engaging social systems, especially religious leaders, is crucial for improving vaccine uptake.

• Barriers to Access: Vaccine availability and waiting times at service delivery points were identified as barriers. Some adolescents felt that vaccination sites were not private enough. Although the HPV vaccine was available at service delivery points, historic stock-outs contributed to perceived stock-outs.

Lessons Learned

• Adolescent Involvement: Engaging adolescents in HPV vaccination programs and using visual aids can improve uptake. Developing HPV IEC materials and programming should include adolescents to address their specific needs.

• Vaccine Availability: Historic stock-outs have led to a perception of vaccine unavailability. Ensuring consistent vaccine supply and regularly communicating stock status can build trust and confidence.

• Waiting Times: Long waiting times can cause frustration and missed opportunities. Optimizing workflows, scheduling appointments, and increasing staffing during peak times can reduce waiting times.

• Privacy Concerns: Lack of private spaces at vaccination sites can deter adolescents. Designating private consultation areas ensures confidentiality and comfort for young girls and their parents.

• Accessibility of Vaccination Sites: Adolescents have limited time to attend conventional health services, especially during school hours. Implementing school-based vaccination programs and offering flexible clinic hours can improve accessibility.

• Screening for Eligible Girls: Low screening rates for eligible girls can result in missed vaccinations. Improving screening processes ensures that eligible girls are identified and vaccinated.

• Perceived Stock-Outs: Perceived stock-outs due to lapses in HPV promotion and historic stock-outs can deter vaccination. Maintaining consistent promotion and clear communication about vaccine availability can dispel misconceptions.

• Awareness Campaigns: Testimonies from cancer survivors and school-based activities, such as quizzes and identifying champions, can raise awareness and risk perception. Incorporating HPV, cervical cancer, and HPV vaccine information into school health curricula can also help.

• Social Systems: Engaging social systems, particularly religious leaders, is essential for improving vaccine uptake. Caregiver norms, peer norms, and community norms play a significant role in influencing vaccination decisions.

Next Steps

• Revitalization Strategy: Insights from the study will inform the development of the National HPV revitalization strategy. The production of HPV SBC materials will involve adolescent girls at all stages.

• Adolescent Engagement: Prioritizing peer education and involving adolescents in the dissemination of HPV vaccination information.

• Continuous Support: UNICEF will continue to support the government in promoting immunization, addressing inequities, and strengthening service improvements and community engagement.