Overcoming HPV vaccine hesitancy: insights from a successful school-based vaccination campaign in the Saa health district of Cameroon | BMC Infectious Diseases

We present the outcomes of a successful HPV vaccination initiative in the Saa health district, where 1,321 adolescents received vaccinations, primarily through a school-based approach, achieving a remarkable 99.4% utilization rate of available vaccines in the district. This campaign was conducted in the context of significant community hesitancy regarding the HPV vaccine, which was influenced by concerns over potential COVID-19 infection, fears of infertility, and opposition from the Catholic Church. Conversely, health professionals attributed this hesitancy to the government’s insufficient efforts in educating the public prior to the introduction of the vaccine. The success of this campaign signifies a notable shift in attitudes toward the HPV vaccine among both health workers and the community. We aim to highlight the changes in perceptions that were observed throughout this initiative.

Changes in attitude observed

Before the campaign, a significant number of health workers rarely engaged in sensitizing pupils and students about HPV, nor did they actively encourage parents to bring their children for vaccination, despite the availability of the vaccine within their cold chain. However, they did conduct sensitization efforts regarding other infant vaccines. Only a small fraction attempted to vaccinate within schools and proactively sought eligible children. During the campaign, nearly all the vaccinators engaged in sensitization activities at schools, churches, and within the community, persuading parents to permit their children to receive vaccinations. The campaign also fostered a sense of intragroup competition and motivation, as each vaccinator strived to match or exceed the performance of their colleagues. Those who were initially hesitant began to schedule vaccinations in schools, leading to a substantial increase in the number of vaccinated children. Notably, no financial incentives were provided to vaccinators for participating in this vaccination initiative. Intrapersonal and interpersonal pride have been identified as motivational factors in the workplace [20, 21], encouraging employees to achieve their goals or exceed their own expectations.

The introduction of the HPV vaccine in 2020 was met with significant opposition from the Vicar General of the Catholic diocese in the area, who strongly criticized the vaccine. He issued a directive prohibiting Catholic churches and schools from disseminating information related to HPV or allowing access to vaccination providers. This stance was unique to the HPV vaccine. However, a shift occurred as Catholic churches began to accept announcements about the vaccination campaign and permitted vaccinators to engage with congregants during services. Some priests even took the initiative to educate their congregations about cancer. A similar change was noted in Catholic schools. This transformation undoubtedly contributed to increased community acceptance of the HPV vaccine, particularly given that a large portion of the population identifies as Catholic. Religion has been cited as a social determinant of health, as believers tend to turn to their spiritual leaders for health guidance [22]. The church plays a significant role in health promotion [23], and organizations such as UNICEF encourage collaboration between the health sector and religious institutions to increase immunization efforts [24].

Schools, much like churches, serve as significant platforms for health promotion [25]. Despite directives from educational authorities, many principals initially denied access to vaccinators for HPV vaccination, primarily due to concerns about potential backlash from parents. However, during the campaign, the majority of principals embraced the vaccinators, facilitated the sensitization of students, and assisted in obtaining parental consent. Notably, after the immunization efforts, no principal reported experiencing any backlash from parents. Research indicates that teachers’ beliefs about vaccination can significantly affect their attitudes toward parental hesitancy [26, 27] and their willingness to allow vaccinations on school grounds [28]. Enhancing teachers’ understanding of the vaccine in question has been proposed as a means to foster a more positive attitude toward vaccination initiatives [26, 29, 30]. Ongoing community sensitization and advocacy efforts with teachers likely played a crucial role in increasing their knowledge about HPV.

Concerns regarding infertility associated with the HPV vaccine have been identified as a significant factor contributing to vaccine hesitancy in various contexts [31, 32], including the Saa health district [19]. The perception that a vaccine aimed solely at girls (who are often viewed as bearers of future generations) poses a threat to reproductive capabilities fueled these fears. Infertility remains a sensitive subject in numerous African communities [33]. However, during the vaccination campaign, the decision to include boys in the vaccination initiative appeared to alleviate some of the anxiety surrounding infertility among local residents. Vaccinators noted that parents exhibited greater openness when informed that boys would also receive the vaccine. Additionally, the occurrence of some teenage pregnancies among girls who had been vaccinated at the program’s inception provided further evidence that the vaccine does not lead to infertility.

The COVID-19 pandemic generated significant fear within communities globally and led to considerable prejudice against immunization services [34]. The introduction of the COVID-19 vaccine presented an opportunity to mitigate the morbidity and mortality associated with the virus. In Cameroon, five rounds of COVID-19 vaccination campaigns were conducted, with each subsequent round achieving a greater number of vaccinations in the Saa health district. This increasing uptake of the COVID-19 vaccine indicated increasing confidence among the community regarding its efficacy. However, the launch of the HPV vaccine coincided with the pandemic, resulting in heightened community hesitancy driven by fears of infection. During the vaccination campaign, community health workers encouraged parents to permit their children to receive the HPV vaccine, highlighting that they themselves had been vaccinated against COVID-19 without experiencing severe side effects or contracting the virus. It appears that the community adopted a wait-and-see approach regarding the HPV vaccine, uncertain about its benefits or potential risks, preferring to observe its effects on other children before making a decision. This cautious parental attitude toward the HPV vaccine has been documented in various contexts [35, 36]. The delay in vaccine uptake hampers disease prevention initiatives and facilitates the transmission of diseases within the community [37, 38].

Numerous systematic reviews have assessed various interventions aimed at improving HPV vaccine uptake among adolescents [39,40,41,42]. Mavundza et al. examined interventions implemented in high-income countries and reported that narrative education, outreach efforts, financial incentives, reminders, and brief motivational strategies directed at recipients significantly increased the initiation of HPV vaccination [39]. Rani et al. focused on interventions in the United States (U.S.) and reported that HPV-related education provided by credible sources positively influenced vaccination rates among adolescents [40]. Conversely, another review investigating interventions among minority populations in the U.S. revealed limited evidence supporting the effectiveness of HPV education and reminders in improving vaccination rates [41]. Oketch et al. analyzed communication strategies for HPV vaccination in Sub-Saharan Africa and concluded that targeting community leaders, educators, school administrators, and health workers effectively enhanced HPV vaccine uptake, owing to their influence on parents and adolescents within the community [42]. Collectively, these studies underscore the necessity for context-specific interventions to boost HPV vaccine uptake. Oketch’s findings resonate with our experiences during the campaign, where the active involvement of key stakeholders—such as health workers, educators, and religious leaders—was instrumental in guiding parents and adolescents to engage with the campaign.

Public health implications

This vaccination activity had several public health implications. Efficient mobilization of resources and active engagement of key stakeholders significantly reduced vaccine wastage. This is particularly crucial in light of the global limitations on HPV vaccine supply and the necessity for equitable distribution. In addition, the participation of teachers, healthcare professionals, and even Catholic priests in awareness initiatives helped build community trust and enhance vaccine acceptance, potentially leading to increased uptake in future routine immunization initiatives. Most notably, the campaign led to a considerable rise in HPV vaccination rates, safeguarding both girls and boys from HPV-related illnesses. Including boys in vaccination efforts plays a vital role in achieving herd immunity, thereby diminishing overall viral transmission and the long-term risk of HPV-associated cancers in both genders. Furthermore, enhancing HPV vaccination coverage is in line with the World Health Organization’s objective of eliminating cervical cancer as a public health issue. This campaign has made significant contributions to primary prevention efforts, ultimately aiding in the reduction of cervical cancer incidence and mortality in Cameroon. The success of the campaign further demonstrates that a school-based strategy should be prioritized for HPV vaccination in the country, particularly in the prevailing context of vaccine hesitancy. Advocacy with local authorities and the implementation of school-based vaccination programs can be replicated in similar environments to enhance HPV vaccine uptake across the nation.

Limitations

The primary limitation encountered during implementation of the campaign was the lack of adequate microplanning, which stemmed from the context and urgency of the organization. This oversight resulted in an inability to assess the size of the target population of 9 to 13-year-olds accurately and the necessary doses to achieve at least 25% coverage. Despite an increase in demand, a cautious strategy was adopted, leading to the procurement of only a limited number of doses from the regional warehouse to avoid surplus vaccines within the district’s cold chain. As a result, certain schools were left unvaccinated due to vaccine shortages. Another issue arose from the failure to schedule some schools, as vaccinators mistakenly believed that the school principals would be reluctant to participate.

Given that this report is purely observational, the success of the campaign may not necessarily translate into sustained behavioral change. Additionally, the effectiveness of a campaign can be influenced by a range of factors, including logistical challenges, varying capacities within the healthcare system, and differences in government and community support. These contextual variables make it difficult to generalize the findings, limiting their applicability across diverse settings and populations.