Human Vaccines & Immunotherapeutics ISSN: (Print) (Online) Journal homepage: www.tandfonline.com/journals/khvi20 Human papillomavirus (HPV) vaccination in a privately funded program in Ghana: A qualitative case study Emmanuel Marfo, Bukola Salami, Charles Adjei & Shannon MacDonald To cite this article: Emmanuel Marfo, Bukola Salami, Charles Adjei & Shannon MacDonald (2024) Human papillomavirus (HPV) vaccination in a privately funded program in Ghana: A qualitative case study, Human Vaccines & Immunotherapeutics, 20:1, 2397219, DOI: 10.1080/21645515.2024.2397219 To link to this article: https://doi.org/10.1080/21645515.2024.2397219 © 2024 The Author(s). Published with license by Taylor & Francis Group, LLC. View supplementary material Published online: 10 Sep 2024. Submit your article to this journal Article views: 1764 View related articles View Crossmark data Full Terms & Conditions of access and use can be found at https://www.tandfonline.com/action/journalInformation?journalCode=khvi20 https://www.tandfonline.com/journals/khvi20?src=pdf https://www.tandfonline.com/action/showCitFormats?doi=10.1080/21645515.2024.2397219 https://doi.org/10.1080/21645515.2024.2397219 https://www.tandfonline.com/doi/suppl/10.1080/21645515.2024.2397219 https://www.tandfonline.com/doi/suppl/10.1080/21645515.2024.2397219 https://www.tandfonline.com/action/authorSubmission?journalCode=khvi20&show=instructions&src=pdf https://www.tandfonline.com/action/authorSubmission?journalCode=khvi20&show=instructions&src=pdf https://www.tandfonline.com/doi/mlt/10.1080/21645515.2024.2397219?src=pdf https://www.tandfonline.com/doi/mlt/10.1080/21645515.2024.2397219?src=pdf http://crossmark.crossref.org/dialog/?doi=10.1080/21645515.2024.2397219&domain=pdf&date_stamp=10%20Sep%202024 http://crossmark.crossref.org/dialog/?doi=10.1080/21645515.2024.2397219&domain=pdf&date_stamp=10%20Sep%202024 https://www.tandfonline.com/action/journalInformation?journalCode=khvi20 RESEARCH ARTICLE Human papillomavirus (HPV) vaccination in a privately funded program in Ghana: A qualitative case study Emmanuel Marfo a, Bukola Salamib, Charles Adjeic, and Shannon MacDonalda aFaculty of Nursing, University of Alberta, Edmonton, AB, Canada; bCumming School of Medicine, University of Calgary, Calgary, AB, Canada; cSchool of Nursing and Midwifery, University of Ghana, Legon, Accra, Ghana ABSTRACT HPV vaccination is one of the safest and most effective interventions against HPV-related cancers. From 2013 to 2018, HPV vaccination was piloted in Ghana in preparation for a national program. Yet, at the time of this study, there was no publicly funded HPV vaccination program in Ghana. We explored an existing privately funded HPV vaccination program in Ghana to identify challenges and gaps and to gather insights to inform vaccination practice and national policy. This study used a qualitative case study research design. We conducted semi-structured interviews on experiences, barriers, and challenges in HPV vaccination at the Greater-Accra Regional Hospital between October 1 and November 26, 2023. Participants (N = 16) included HPV vaccinators (n = 8) and program/policy leaders (n = 8). Our thematic analysis focused on HPV vaccination processes, practice challenges, and policy interests. Four main themes emerged from our analyses. Our findings revealed many challenges faced by the HPV vaccination program. These include a lack of guiding policy/framework for the HPV vaccination program, an emphasis on sexual history, cervical screening, and HPV DNA test in determining vaccination eligibility by vacci nators, and a lack of formal provider and recipient HPV education programs. Although many vaccinators advocated for a universal HPV program, some policy/program leaders were reluctant to prioritize HPV vaccination advocacy due to their focus on acute health concerns. A vaccination program without a policy can be limited in quality and efficiency, as there will be no accountability and sustainability measures. We recommend the need to develop standardized guidelines to support evidence-based HPV vaccination practice. ARTICLE HISTORY Received 25 May 2024 Revised 9 August 2024 Accepted 23 August 2024 KEYWORDS Privately-funded HPV vaccination program; HPV vaccination practice recommendations; HPV vaccination policy and advocacy; Ghana Introduction Research shows that human papillomavirus (HPV) vaccina tion is one of the safest and most effective preventive inter ventions against HPV-related diseases, including cancers of the cervix, mouth, throat, and genitals.1–3 In 2013, the Global Alliance for Vaccination and Immunization (Gavi)introduced an HPV vaccination pilot project in Ghana.4,5 The project aimed to prepare stakeholders with the prerequisite knowledge and skill sets required for a national program on HPV vaccina tion. Although the demonstration project ended in 2018, scal ing up to the national level is pending (see Figure 1).6 Currently, there is no publicly funded HPV vaccination program in Ghana and HPV vaccination is only accessible through privately funded programs in a few government and private clinics in urban areas, rendering it inaccessible to a large population of intended beneficiaries.7 Immunization is among the many essential health services excluded from Ghana’s National Health Insurance Scheme.8 Through indivi dual initiatives, some public and private hospitals have incor porated private HPV vaccination services in their reproductive health programs. These hospitals independently manage all aspects of the HPV vaccination program, including procure ment, administration, and follow-up. These programs are funded through out-of-pocket charges, locally called “cash and carry”, with services and vaccine costs paid by patients. Like neighboring Nigeria, which recently introduced a publicly funded HPV vaccination program,9 there may be a national HPV vaccination program in Ghana soon. Specifically, the Ghana Health Service announced plans for a publicly funded HPV vaccination program for pre-adolescent and adolescent girls by the end of 2024.10 However, details of the program (e.g., vaccination delivery, awareness, doses) are yet unknown. Previous HPV vaccination studies in Ghana have focused mainly on knowledge, awareness, acceptance, intentions, and willingness to receive HPV vaccination.11–19 There remains a gap in understanding about HPV vaccination processes and barriers in the Ghanaian context. Additionally, there is a paucity of studies that explored privately funded HPV vacci nation programs in low- and middle-income countries, includ ing Ghana. These knowledge gaps justify further research to inform HPV vaccination policy and practice in Ghana. In anticipation of a publicly funded HPV vaccination pro gram in Ghana, we aimed to explore a current privately funded HPV vaccination program to identify practice challenges and gaps, and to gather insights to inform practice and national policy. We asked the following research questions: (a) How is the HPV vaccination program at the Greater-Accra Regional Hospital functioning, and (b) What practice and policy CONTACT Emmanuel Marfo marfo@ualberta.ca Faculty of Nursing, Level 3, Edmonton Clinic Health Academy, Edmonton, Alberta T6G 1C9, Canada. Supplemental data for this article can be accessed on the publisher’s website at https://doi.org/10.1080/21645515.2024.2397219 HUMAN VACCINES & IMMUNOTHERAPEUTICS 2024, VOL. 20, NO. 1, 2397219 https://doi.org/10.1080/21645515.2024.2397219 © 2024 The Author(s). Published with license by Taylor & Francis Group, LLC. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. The terms on which this article has been published allow the posting of the Accepted Manuscript in a repository by the author(s) or with their consent. http://orcid.org/0000-0002-9654-404X https://doi.org/10.1080/21645515.2024.2397219 http://www.tandfonline.com https://crossmark.crossref.org/dialog/?doi=10.1080/21645515.2024.2397219&domain=pdf&date_stamp=2024-09-06 challenges exist in the HPV vaccination program? Findings from this study will contribute to informing HPV vaccination practices and future policy in Ghana. Furthermore, this study will offer insights into strengthening privately funded pro grams for populations who may not meet the eligibility criteria of the national program but will benefit from HPV vaccina tion. Last, lessons from this study may be adopted and adapted for HPV vaccination decision-making and policy in neighbor ing sub-Saharan African countries. Materials and methods Research design and theoretical approach This study is part of a larger project which used a qualitative case study research design to explore a privately funded HPV vaccination program in Ghana. Qualitative case study design assists in answering questions about how and why a contemporary event occurs in a specific real-life context.20 We used this design because it offers an in-depth multi- perspectival approach (e.g., triangulation of methods and data sources) to explore the current HPV vaccination program.20 The ‘case’ in this project was the Greater-Accra Regional Hospital, and the unit of analysis for the project was the privately funded HPV vaccination program between 2019 and 2023. To explore the unit of analysis, we included HPV vaccinators (i.e., clinic staff who provide HPV vaccines), pro gram/policy leaders (i.e., hospital administrative staff, direc tors of health involved in policy making at the national level, and private HPV vaccine suppliers), and HPV vaccine recipi ents (i.e., individuals who received HPV vaccines from the clinic) at the hospital. Using an interpretivist approach, which focuses on the subjective experiences of stakeholders and how that is shaped by the clinic’s social context to under stand the HPV vaccination program,21 this study reports on vaccinators’ and program/policy leaders’ perspectives and experiences in the current HPV vaccination program at the hospital. The study was guided by intersectionality theory, which posits that multiple social identities and locations interact at individual levels to produce and sustain inequalities and power differentials at both individual and structural levels.22,23 Previous studies showed that individual identities (i.e., gen der/sex, age, education, and class) and structural factors (e.g., policy, politics, and social norms) are relevant modifiers that shape HPV vaccination and its acceptance,24–26 justifying its suitability to this study. Our use of intersectionality granted analytical insights into identifying how individual and struc tural systems intersect to shape the HPV vaccination program in this context. Researcher characteristics and reflexivity The project team included four researchers, three from Canada and one from Ghana, who identified with diverse gender/sex, race, and ethnicity. The team comprised research experts in HPV vaccination research and health policy, case study research design, intersectionality theory, and sexually trans mitted and blood-borne infection research within the Ghanaian context, which facilitated a multi-perspective approach to conceptualizing and conducting this study through ongoing consultations Study setting The setting for the study was the Greater-Accra Regional Hospital, located at the Osu-Klottey Sub-Metro of the Accra Metropolitan Assembly in the Greater-Accra Region of Ghana. Established in 1928, the hospital is the second largest hospital Figure 1. Evolution of HPV vaccination programs in Ghana. 2 E. MARFO ET AL. in the Greater-Accra Region, serving over 4,671,363 people in its catchment area. We selected this hospital for the study because it is among the few in Ghana with established cervical cancer prevention programs, including a privately funded HPV vaccination program. The HPV vaccination program is offered at the Family Planning Unit of the hospital. The Family Planning Unit is run by eight nurses (vaccinators) who refer advanced clinical cases to physicians at the Obstetrics and Gynecology Department of the hospital. Sampling strategy We recruited vaccinators and program/policy leaders involved in the hospital’s HPV vaccination program, using purposeful sampling. Purposeful sampling allowed us to identify and include participants with experiences in the HPV vaccination program.27 Criteria for inclusion were participants with a minimum of 3 months of involvement in the HPV vaccination service delivery or decision-making between 2018 and the time of data collection, as we were interested in perspectives after the Gavi-funded pilot project ended. No interested participants were excluded based on any identity such as gender, sex, age, or professional rank. We aimed to recruit as many possible participants who were interested in participating in the study. We purposefully invited all vaccinators at the clinic (n = 8), vaccination program leaders at the hospital (n = 10), and national health directors involved in vaccination policymaking (n = 2) through recruitment letters. During data collection, we recognized a relevant stakeholder (i.e., a private HPV vaccine supplier), who we invited (n = 1) to participate in the study to provide a comprehensive understanding of the program. One national health director did not respond to the invitation and four policy/program leaders did not participate in the interviews citing unavailability due to professional duties and vacation. The lead author provided information letters to potential partici pants and obtained written informed consent before interviews. After the sixteenth interview, the research team determined through discussion of interviews and consensus that we have obtained enough rich data to answer our research questions, and thus concluded interviews.28,29 Ethics approval The research team obtained approval from the University of Alberta Ethics Review Board (#Pro00124946) and the Ghana Health Service Ethics Review Committee (Protocol ID NO: GHS-ERC 003/09/23). The Greater-Accra Regional Directorate of Health also provided permission for this study. Data collection methods and tools The lead author observed the HPV vaccination clinic for 3 weeks before conducting any semi-structured interviews to capture the events, social interactions, and processes that occurred at the clinic. Clinic observations were documented in field notes. To ensure consistency in data collection, we developed separate interview guides for each participant category (i.e., vaccinators and program/policy leaders) informed by relevant HPV vaccination literature and reviewed by the research team, which included experts in HPV vaccination, qualitative research, and health research with the Ghanaian population and context. The interview guides were piloted with two nurses working in the reproductive health unit and a physician in a different hospital in Accra and incorporated feedback for improvement. The interview questions explored demo graphics; vaccination practices; practice guidelines; percep tions about the HPV vaccination program and clients; and policy directions (see Supplementary File 1 for interview guides). The lead author conducted all interviews in English (the official language in Ghana). All interviews were in person, and the average interview duration was 34 min. In all, 16 participants, including vaccinators (n = 8) and program/policy leaders (n = 8), completed interviews between October 1 and November 26, 2023. Participants received incentives for parti cipation and those whose participation involved traveling received reimbursement for the travel cost. Interviews were audio-recorded with participants’ consent and transcribed verbatim by a research assistant. Data analysis and rigour The HPV vaccination literature and the semi-structured inter view guide aided our deductive thematic analysis in NVivo software version 12 (QSR International, Burlington, MA) using the framework method.20,30–32 The lead author deduc tively coded all transcripts separately and a research assistant independently coded four transcripts in duplicate.33,34 Coding validation occurred between the lead author and the research assistant to discuss and compare codes, identify aligned codes, and reconcile the final analytical framework for iterative coding.35 Our coding focused on identifying evidence illustrat ing vaccination processes, practice challenges, policy interests and participant perspectives about HPV vaccination in the clinic. Throughout the coding process, the lead author con sulted and discussed the emerging categories and themes with sample quotes through regular meetings with the project supervisor (S.E.M) for input and feedback and shared emer ging themes with the team members via e-mail communica tions for further insights. We compared emerging codes from the transcripts to identify categories and patterns and orga nized them into themes. Our analysis benefitted from a team of researchers, which included registered nurses and researchers with expertise in HPV vaccination research, qualitative research practices, and experiences working with the Ghanaian population. The lead author recorded personal reflections in memos, discussed them with the project super visor during regular meetings, and shared emerging themes with the team members via e-mail communications for further insights. We ensured trustworthiness through member- checking by sharing password protected transcripts with five randomly selected participants to assess data accuracy36 and presented the findings of this study using the Standard for Reporting Qualitative Research guideline37 (see Supplementary File 2). Additionally, we maintained trust worthiness by ensuring dependability (i.e., a precise descrip tion of study methods), credibility (i.e., prolonged data engagement, iterative coding, and member-checking), HUMAN VACCINES & IMMUNOTHERAPEUTICS 3 confirmability (i.e., provision of steps in data analysis), and transferability (i.e., a detailed description of study context and participants)” Results Participant characteristics Interview participants (N = 16) included vaccinators (n = 8) and program/policy leaders (n = 8). The program/policy lea ders included administrative and relevant department heads within the Greater-Accra Regional Hospital (n = 6), National Director of the Family Health Division of Ghana Health Service (n = 1), and a private vaccine supplier (n = 1). All vaccinators were females with clinic experiences ranging from 3 months to 22 years and with post-secondary education. Most of the program/policy leaders were males (n = 5) and held a graduate degree (n = 6) (see Table 1: Participants’ Characteristics). Overview of interview findings Four themes about HPV vaccination at the clinic emerged: 1) clinic operations and vaccination processes, 2) attitudes toward vaccination program and scale-up 3) clinic operational barriers and 4) institutional challenges with HPV vaccination (see Table 2: descriptions of codes, codes, categories/sub- themes, and themes). We present a detailed report of the themes and their respective sub-themes below. All partici pants’ names are pseudonyms. Theme 1: Current clinic operations and vaccinationprocesses Participants discussed routine operations and functions that guide HPV vaccination in the clinic. There were uncertainties about whether there was an existing policy for the HPV vacci nation program. Education and awareness about the availabil ity of HPV vaccination are opportunistic and contingent on family planning unit visits. Vaccinators devised culturally aligned strategies to convince parents to vaccinate their ado lescent children against HPV. Uncertainty about existing policy for HPV vaccination Participants were uncertain about an existing policy for the HPV vaccination program. Salamatu (a vaccinator) explained: “We have handouts on that [HPV Vaccination] and then [. . .] we have [an] atlas on that as well.” In contrast, Cordelia (the unit manager) indicated: “We don’t have any . . . not any rigid algorithms”, and there is “no, not that I know of [policy]” for the vaccination program. Similarly, a policymaker at the national level mentioned that there is no national policy specific to HPV vaccination. Dr Asaya (Director of Family Health Division, Ghana Health Services), explained: What happens is that it’s [HPV vaccination] captured as part of policies for immunization against vaccine-preventable diseases in general whether they are for reproductive health purposes or dis eases so you find out [in] policy, they say well these [HPV vaccina tion] are candidates for future inclusion. Strategies for HPV vaccine recipient education Vaccinators utilize opportunistic family planning unit visits, outpatient department (OPD)-talks, and cervical cancer awareness month to educate vaccine recipients and clinic visitors on HPV prevention and vaccination. Omaama (a vac cinator), described their teaching approaches for HPV preven tion and vaccination: It [education]’s a daily thing when it comes to this particular unit [Family Planning]. Because clients who come for family planning services and other services, we take the opportunity to educate them on the HPV and then suggest that there is a vaccine . . . Some vaccinators described the cervical cancer awareness month as a period for maximizing HPV vaccination education on a larger scale. Cordelia elaborated: “. . . we do the larger one when the national and international awareness creation comes in. It’s January, February . . . and then we try, through that, we do a lot of education.” The vaccinators reported using culturally aligned strategies to encourage parents to vaccinate their adolescent children. Table 1. Participants’ characteristics. Pseudonym Sex Practice duration in the unit (years) Educational level HPV vaccinators Akwene F 5 Diploma Alison F 3 Bachelor’s Asantewaa F 13 Bachelor’s Cordelia F 22 Master’s Korley F 0.25 Diploma Omaama F ~2 Diploma Salamatu F 5 Diploma Vanessa F 2 Bachelor’s Program/policy leaders Roles In hospital Alex M Hospital Administrator Master’s Dr. Anokyewaa F Acting Head, Public Head Department Medical degree and MPH Dr. Dominics F Head, Adolescent Health Center Medical degree and MPH Grace F Head, Nursing Master’s Dr. Kwaa-Appiah M Head, Obstetrics & Gynae Team A Medical degree and MPH Zen M Head, Department of Pharmacy Bachelor’s Out hospital Dr. Asayah M Director, Family Health Division (Ghana Health Service) Medical degree and MPH Oti M Private HPV vaccine supplier Bachelor’s 4 E. MARFO ET AL. Ta bl e 2. T he m es , i llu st ra tiv e qu ot es , c od e de sc rip tio n, c od es , c at eg or ie s/ su b- th em es . Sa m pl e ill us tr at iv e qu ot es Co de d es cr ip tio n Co de s Ca te go rie s/ Su b- th em es Th em e 1: C ur re nt c lin ic o pe ra ti on s an d va cc in at io n pr oc es se s - I k no w t he re ’s a po lic y by t he G ha na H ea lth S er vi ce w hi ch h as b ee n ad op te d by t he G re at er A cc ra R eg io na l H os pi ta l- Ze n - So , I c an ’t re al ly t al k to t ha t pa rt ic ul ar t hi s th in g. B ut I kn ow t he re ’s a po lic y, a nd w he n It’ s be in g re vi ew ed , I d on ’t kn ow t he e xa ct t hi s th in g. S o, I ha ve t o be fr an k ab ou t th at p ar tic ul ar o ne - Ze n - T he re a re so m an y, w e ha ve so m an y. W e ha ve th e on e th at d ea ls w ith th e tr an sf or m at io na l z on es a nd . . . th en w e al so h av e th e on es t ha t de al s w ith c lie nt ’s H IV – A lis on - Pl ea se , n ot a ny r ig id a lg or ith m . . . N o, n ot t ha t I k no w o f – C or de lia - I h av en ’t co m e ac ro ss a ny [p ol ic y] – K or le y - N o, w e do n’ t h av e po lic y . . . ju st n o, w e do n’ t b ec au se a s I s ai d w e do n’ t h av e im m un iz at io n sc he du le s . . . -D r. D om in ic s - Th er e m ig ht b e, b ut t he la st t im e I s aw it w as , I t hi nk , w e’ re in O ct ob er , r ig ht ? I s aw it in J ul y – O m aa m a Fo rm al H PV v ac ci na tio n pr ac tic e do cu m en ts G ui di ng P ol ic y, gu id el in es , p ro to co ls , al go rit hm s U nc er ta in p ol ic y fo r H PV v ac ci na tio n - So , i f t he p er so n w al ks in fo r fa m ily p la nn in g, y ou t al k to h er a bo ut t he c an ce r sc re en in g. E ve n th ou gh s he di dn ’t w al k in b ec au se o f t ha t, lik e to g iv e th e op po rt un ity to te ll he r o r l et k no w th at th er e is so m et hi ng li ke th at . A nd a fte r th at , y ou s til l h av e a va cc in e fo r th em – A sa nt ew aa - M os t of te n, w he n th ey . . . th ey p ar en ts c om e ar ou nd , w e do te ll th em a nd if th ey h av e th ei r da ug ht er s, w ho ar e ye t to g iv e bi rt h – Ko rle y - I t [ ed uc at io n] ’s a da ily th in g w he n it co m es to th is pa rt ic ul ar u ni t [ Fa m ily P la nn in g] . B ec au se c lie nt s w ho c om e fo r f am ily p la nn in g se rv ic es a nd o th er se rv ic es , w e ta ke th e op po rt un ity to e du ca te th em o n th e H PV a nd th en su gg es t th at t he re is a v ac ci ne . . . O m aa m a - W he ne ve r w e ge t th e op po rt un ity S al am at u - S om et im es w he n th ey c om e, I te ll th em , y ou sh ou ld k ee p it [r ec ei pt ] a nd w he n yo ur in -la w c om es in to p ay th e do w ry , y ou a dd th e re ce ip t t o it, th en h e pa ys b ec au se y ou h av e pr es en te d th e se rv ic e fo r h im – A sa nt ew aa - I a lso t ol d th em [p ar en ts ] t ha t yo u ca n gi ve t he v ac ci ne e ve n as a b irt hd ay g ift t o th at c hi ld – A lis on St aff a ct iv iti es t o ed uc at e or t ea ch c lin ic v is ito rs or t he p ub lic a bo ut H PV v ac ci na tio n. Ed uc at io n pr og ra m s, aw ar en es s st ra te gi es St ra te gi es fo r ed uc at in g ta rg et H PV va cc in e re ci pi en ts W e m ak e su re y ou d o th e te st a nd t he t es t ha s to b e ne ga tiv e be fo re w e pr oc ee d w ith it [H PV v ac ci na tio n] – Va ne ss a - w e w an t t o fin d ou t i f y ou ’re s ex ua lly a ct iv e, if y ou a re , y ou a re s up po se d to g o th ro ug h th e te st in g th at is th e H PV t es t – Al is so n - ‘le t’s s ay s he ’s 25 y ea rs a nd s ex ua lly a ct iv e, w e ne ed t o sc re en t ha t w om an . A nd if s he ’s ne ga tiv e, t he n sh e qu al ifi es t o ta ke t he v ac ci ne . I f p os iti ve , t he n yo u ne ed t o do s om e te st a nd it s pa rt o f s om e of t he re qu ire m en ts ” – Co rd el ia - A ha a, s o w he n th ey [a do le sc en ts ] c om e, p er c ou ns el lin g, m os t o f t he m a re v irg in s, so w e ca pt ur e th em w he n th ey h av e no t in iti at ed s ex . S o, t he y w ill t ak e th e va cc in e w ith ou t th e sc re en in g – As an te w aa Pr io r in ve st ig at io ns b ef or e H PV v ac ci na tio n ad m in is tr at io n H PV t es t, sc re en in g, se xu al a ct iv ity Em ph as is o n se xu al ity , s cr ee ni ng , a nd tr ea tm en t be fo re H PV v ac ci na tio n Th em e 2: A tt it ud es T ow ar ds H PV V ac ci na ti on P ro gr am a nd S ca le u p - I h av e re ce iv ed t he t ra in in g at t hi s un it or fa ci lit y, I am a bl e to o r I a m a llo w ed – O m aa m a - I h av e kn ow le dg e on t ha t al re ad y, s o I’m a lw ay s pr ep ar ed – A kw en e - I n sc ho ol , [ . . .] w e w er e ta ug ht a bo ut th is ob st et ric a nd m ed ic in e. W e de al w ith w om en , [ th e] p el vi s, an d th en th e vu lv a, w e w er e ta ug ht [. . .] ho w th e vu lv a lo ok s an d al l t ho se th in gs . . . s o, li ke [. . .] fr om th e kn ow le dg e I h av e, I th in k th e hu m an p ap ill om av iru s is us ua lly h id de n ar ou nd th e co lu m na r ep ith el ia ju nc tio n [. . . ]. So , w ith t ha t, I’m a bl e to u se t ha t to g et m or e in fo rm at io n . . . w he n yo u ap pl y th e ac et ic a ci d an d . . . if it is ne ga tiv e to o, y ou ’re a bl e to te ll . . . ba se d on th at y ou c an e nc ou ra ge th e pe rs on to g o in fo r t he v ac ci ne if sh e ca n? – S al am at u Va cc in at or s’ vi ew s ab ou t re ad in es s to ad m in is te r H PV v ac ci na tio n Pr ac tic e sc op e, p re vi ou s tr ai ni ng Pe rc ei ve d pr ep ar ed ne ss fo r H PV va cc in at io n (C on tin ue d) HUMAN VACCINES & IMMUNOTHERAPEUTICS 5 Ta bl e 2. (C on tin ue d) . Sa m pl e ill us tr at iv e qu ot es Co de d es cr ip tio n Co de s Ca te go rie s/ Su b- th em es - I t hi nk t he h os pi ta l’s fo cu s w as o n th e fa m ily p la nn in g – As an te w aa - I w ou ld p rio rit iz e he pa tit is B – Ak w en e - I’m r ig ht n ow t ak in g ca re o f [ . . .] y ou ng p eo pl e liv in g w ith T yp e 1 D ia be te s an d fo r ex am pl e, t he y ne ed in su lin t o liv e an d I’m t ry in g to e ve n ge t th at t o be t ak en c ar e of b y th e N H IS . . . S o it’ s so rt o f y es , w e do n ee d im m un iz at io ns fo r a do le sc en ts , [ . . .] b ut fo r r ig ht n ow , I w ou ld s ay it is no t m y pr io rit y rig ht n ow a s pu sh in g be ca us e ev en t he in su lin t ha t is ne ed ed t o liv e ha sn ’t be en d on e” – D r. D om in ic s - Bu t th en t he w ho le t hi s th in g is th at y ou w ill t he n pr io rit iz e an d yo u lo ok fo r ve ry a cu te is su es ”- D r. As ay ah - Bu t y ou fi nd t ha t he al th in su ra nc e is m uc h m or e on c ur at iv e. Y ou fa ll sic k th en y ou g et t o . . . yo u- yo u go t o ho sp ita l, th en w he n yo u do t hi s, th en -t he n th ey w ill p ay . . . D r. As ay ah - Ye ah , s o it [c er vi ca l c an ce r] d oe sn ’t fa ll in to t he s ph er e of t hi ng s w he re y ou d efi ne a s m at er na l m or ta lit y . . . H er e I’m d ea lin g w ith t w o in di ca to rs , m at er na l m or ta lit y. S o, if a w om an d ie s of c er vi ca l c an ce r, it’ s no t m at er na l m or ta lit y . . . It’ s ju st a w om an w ho h as d ie d” – D r. As ay ah H ea lth in te rv en tio n pr io rit ie s by p ol ic y/ pr og ra m le ad er s H ea lth ca re p rio rit ie s Fo cu s on a cu te h ea lth c on ce rn s - t he M in ist ry o f H ea lth a nd th e W om en a nd G en de r, if th ey c an a ll co m e to ge th er s o th at w e ca n do s om et hi ng ab ou t it fo r th e co st t o be s ub sid iz ed , i t w ill h el p – Ko rle y - S o, if th e go ve rn m en t s ho ul d co m e in a nd w e ge t a s ub sid iz ed v ac ci ne , i t w ill h el p. W e ca n re ca ll w he n CO VI D - 19 c am e an d w he n th e va cc in es w er e m ad e re ad ily a va ila bl e, t ho ug h a lo t of p eo pl e di dn ’t un de rs ta nd be ca us e of [a ] k no w le dg e de fic it, [. . .] bu t th e la rg er G ha na ia n w en t fo r th e va cc in e. S o, I’ m s ur e th at if t he H PV v ac ci ne is m ad e av ai la bl e lik e th e CO VI D -1 9 va cc in e, p eo pl e w ill c om e an d va cc in e – N aa - t he v ar io us h os pi ta ls th at d o th e sc re en in gs a re to in fo rm h ig he r a ut ho rit ie s th at th es e ar e th e th in gs w ee a re en co un te rin g . . . so M in ist er w hy d on ’t yo u br in g th e go ve rn m en t t o re du ce th e va cc in es s o th at th e yo un ge r on es c an s ta rt t ak in g th e va cc in es – V an es sa - I d on ’t m ak e po lic ie s, so it ’s di ffi cu lt to s pe ak to th at [t he y] w ill te ll yo u th at th er e no m on ey - D r. Kw aa A pp ia h - So , o bv io us ly , t he re a re m or e hi gh er p ow er s in t he re t ha t w ou ld h av e to t ak e ca re o f t he c os ts . . . S o I d on ’t th in k I h av e a vo ic e w he n it co m es it ’s co nc er ni ng g et tin g it in to t he E PI – D r. An ok ye w aa I’m a t t he G ha na H ea lth S er vi ce s, an im pl em en tin g ag en cy . S o, o nc e it’ s im pl em en te d w hy n ot a s a fa ci lit y- le ve l pu bl ic h ea lth p hy sic ia n? I w ill d efi ni te ly b e gl ad a nd fo llo w g ui de lin es a nd d o as I’ m t ol d so a ga in , I h it it ag ai n th at I am n ot th e po lic y fo rm ul at or , I ’m s ur e th ey k no w w ha t t he y ar e do in g up th er e, I am ju st u nd er an im pl em en tin g ag en cy – D r. An ok ye w aa - If th ey c an g iv e it fo r fr ee , o h ye s, w e ca n ha ve a w ho le , y ou k no w , w e go o ut t he re , g o fo r ca m pa ig ns , y ou kn ow , a w ay th er e, ta lk a bo ut , y ou k no w , j us t, er m y ea h, w e w ou ld b e ab le to , a nd ; a nd it ’s av ai la bl e, y ou c an co m e fo r it – D r. D om in ic s Pa rt ic ip an t ex pr es se s ac tiv e su pp or t an d re co m m en da tio n fo r a un iv er sa l H PV va cc in at io n pr og ra m . Su bs id iz e co st , f re e ac ce ss Ad vo ca cy fo r a pu bl ic ly -f un de d H PV pr og ra m Th em e 3: C lin ic O pe ra ti on al B ar ri er s - T he re is n ot hi ng y ou c an d o. B ec au se a t t he e nd o f t he d ay , t he s ho rt ag e so m et im es is n ot o nl y co m in g fr om th is un its , b ut it ’s lik e fr om n at io nw id e- A lis on - Th er e w as a s ho rt ag e so m et im e, s o w e ha d to r el y on e lse w he re – A kw en e - I w ou ld s ay a lo t p eo pl e at th e tim e th ey w al ke d in to c om e fo r t he v ac ci na tio n, th ey a ct ua lly h ad th e m on ey w ith th em . H ow ev er , d ue to d el ay o r i f t he v ac ci ne is n ot in st oc k, so m et im es so m e of th em d on ’t co m e ba ck – O m aa m a - It’ s lik e th e va cc in e is no t av ai la bl e, s o w ha t ha pp en s is so m eb od y ca n st ar t an d th en m ay be is d ue fo r th e se co nd s ho t an d th en t he p eo pl e w al k in a nd t he n w e do n’ t ha ve s om e in s to ck – S al am at u - I w ish it c ou ld b e ac ce ss ib le in t er m s of c os t av ai la bi lit y – D r. D om in ic s Pa rt ic ip an t di sc us se s su pp lie s fo r H PV va cc in at io n Va cc in e su pp ly H PV v ac ci ne u na va ila bi lit y an d sh or ta ge (C on tin ue d) 6 E. MARFO ET AL. Ta bl e 2. (C on tin ue d) . Sa m pl e ill us tr at iv e qu ot es Co de d es cr ip tio n Co de s Ca te go rie s/ Su b- th em es Yo u kn ow o ur s ys te m n ow , t he re is n o tr ai ni ng t ha t’s g oi ng o n m uc h – As an te w aa - W e do p er so na l r ea di ng - Co rd el ia - th e w or ks ho p so fa r ha s be en o n fa m ily p la nn in g, I st ill g o to t he n et - Ko rle y - . . . T he re is n o pr og ra m th at h as b ee n or ga ni ze d on th at [H PV v ac ci na tio n] . W e do m os t o f t he th in gs o n ou r ow n be ca us e th e tr ut h is, w e’ ve n ev er h ad a ny w or ks ho p th at s tr ic tly t al ke d ab ou t th is H PV v ac ci ne – Sa la m at u Pa rt ic ip an t ta lk s ab ou t ed uc at io na l a ct iv iti es t o im pr ov e H PV v ac ci na tio n kn ow le dg e an d sk ill . St aff e du ca tio n, s ta ff tr ai ni ng La ck o f f or m al S ta ff ed uc at io na l a nd tr ai ni ng p ro gr am s ta ilo re d to H PV va cc in at io n Th em e 4: In st it ut io na l c ha lle ng es w it h H PV v ac ci na ti on d ec is io n- m ak in g - I t hi nk w e ne ed t o do a lo t m or e to b rin g ou t ou r da ta - Co rd el ia - W e do m on th ly re po rt . S o, th ey h av e th e da ta . I d on ’t re al ly k no w w ha t t he y us e it fo r. I d on ’t kn ow ”- Va ne ss a - I t w ill b e di ffi cu lt be ca us e th e ad m in ist ra tio n, I do n’ t t hi nk th ey w ill h el p, le t m e sp ea k th e tr ut h, b ec au se w ha t be ne fit s is it to th e ho sp ita l? A ha a, so w he n w e’ re ta lk in g ab ou t v ac ci na tio n, [. . .], n or m al ly th ey u se th e CW C [C hi ld W el fa re C lin ic s] v ac ci na tio n fo r th ei r re po rt s . . . Th is on e [H PV v ac ci na tio n] , n or m al ly , w e do n’ t us e it fo r ou r re po rt b ec au se t he h os pi ta l i s no t pr ov id in g th e va cc in e – As an te w aa - O ffi ci al ly , w e do n’ t kn ow a bo ut it [H PV v ac ci na tio n pr og ra m a t th e G re at er -A cc ra R eg io na l H os pi ta l], t he y w ill t he n ha ve t o re ac h a po in t an d sim pl y sa y, w e th in k w e ha ve ge ne ra te d en ou gh e vi de nc e, w e th in k ha ve ge ne ra te d en ou gh t o be a bl e to m ak e su re t ha t . . . it [H PV v ac ci na tio n] n ee ds t o be s ca le d- up - D r. As ay ah Pa rt ic ip an t di sc us se s us e of e vi de nc e to in fo rm H PV v ac ci na tio n pr og ra m D at a, r ep or t La ck a nd d is us e of H PV v ac ci na tio n da ta - . . . t he e xi st in g G av i p ro gr am , w e pa y [a ] c ou nt er pa rt , a nd w e ar e su pp os ed to b y a ce rt ai n tim e [. . . ] b e on o ur ow n, so w ha t h ap pe ns ? So , t hi s o ne [c ur re nt E PI ] y ou [G ha na ] a re st ill st ru gg lin g to b e on y ou r o w n [a nd ] y ou ar e br in gi ng a no th er o ne – D r. As ay ah - . .If th er e’ s a di se as e w hi ch is c au sin g 30 % o f y ou r m or ta lit y an d so m eb od y w ho c au se s 2% o f m or ta lit y, w he re w ou ld y ou p ut y ou r m on ey ? Yo u w ou ld d efi ni te ly p ut y ou r m on ey o n th e 30 % [. . .]. B ut if y ou g o in a nd d ea l w ith t he 2 % , y ou s til l h av e m an y m or e pe op le d yi ng o r ge tt in g sic k [. . . ]. Th at ’s w hy y ou fi nd m al ar ia g et s m or e at te nt io n th an a ny th in g el se . . . – D r. As ay ah - c er vi ca l c an ce r i s no t t he o nl y ca nc er . T he re a re o th er e rm c an ce rs ; c hi ld ho od c an ce rs a re th er e, m al e ca nc er s ar e th er e, a nd a ll th os e th in gs . W hy a re y ou s up po rt in g ce rv ic al c an ce r? W hy a re y ou n ot s up po rt in g, y ou un de rs ta nd ? So , t he re a re a lo t of c on tr ov er sie s an d po lic y bi as es w he n it co m es t o so m e of t he se t hi ng s – D r. Kw aa h Ap pi ah - be ca us e in t he W es te rn w or ld , t he y ha ve p ro gr am s fo r w he re t he y ha ve p ro gr am s fo r al l t he o th er c hi ld re n ca nc er , t he y ha ve p ro gr am s fo r ce rv ic al c an ce r, th ey e ve n ha ve p ro gr am s fo r en do m et ria l c an ce rs . . . r ig ht Co lo re ct al c an ce rs a nd a ll th at . W he n yo u ar e 50 y ea rs y ou g o . . . yo u ne ed t o go t hr ou gh e rr hm m co lo no sc op y an d al l t ho se t hi ng s. W e do n’ t ha ve a ll th os e pr og ra m s he re . W hy a re y ou s ta rt in g w ith c er vi ca l c an ce r? W hy a re y ou n ot s ta rt in g w ith t hi s? S o, it ’s a lo t of po lic y w or k he re . . . D r. Kw aa h Ap pi ah - S o no w , a s a co un tr y, w he re d o yo u pu t y ou r m on ey fo r t he g re at es t i m pa ct , l ik e I s ai d in th e be gi nn in g . . . So de fin ite ly y ou w ou ld h av e to p ut it s av in g th e m ot he rs a nd n ot fo r c hr on ic d ise as e. C hr on ic d ise as es a re q ui te a di ffe re nt t hi ng a lto ge th er – D r. As ay ah - Ev en if y ou c om e an d w ha te ve r it is, s ur ge ry , c he m ot he ra py a nd a ll th os e, s o th ey m an ag e to p ro m ot e th e qu al ity o f l ife . B ut r ig ht n ow , w e ha ve – w e ha ve n ot r ea ch ed t he re y et . W e ar e st ill d ea lin g w ith t he fu nd am en ta ls. T he is su es w hi ch a re fo r o ur v er y ex ist en ce . B ec au se if y ou re al ly h av e m an y in fa nt s d yi ng , v er y hi gh in fa nt m or ta lit y ra te s, th en y ou t el l p eo pl e to p ut y ou r m on ey in t he re . . . Y ou s ee , w ha te ve r it is. Y es , ac ad em ia , r es ea rc h, e ve ry th in g th en c om es th e po lic y sp ac e . . . An d th at is th at is th e w ho le k in d of ju gg lin g ar ou nd a nd t he in tr ic ac ie s of po lic y. – D r. As ay ah - B ut w e ar e al so c on ce rn ed w ith th e re so ur ce s be ca us e w e ca nn ot p ro vi de th e va cc in es o n ou r o w n, u sin g ou r ow n re so ur ce s t o bu y an d m ak e it fin an ci al ly a cc es sib le . W e ar e lim ite d by o ur o w n bu dg et c on st ra in ts – A le x Pa rt ic ip an t re sp on se s ab ou t a na tio na l H PV va cc in at io n po lic y in te re st Po lic y in te re st , de ci si on -m ak in g Et hi ca l d ile m m as a bo ut H PV v ac ci na tio n po lic y- m ak in g HUMAN VACCINES & IMMUNOTHERAPEUTICS 7 Asantewaa explained: “Sometimes when they come, I tell them, you should keep it [receipt] and when your in-law comes in to pay the dowry, you add the receipt to it, then he pays because you have presented the service for him.” Similarly, Alison dis cussed that “I also told them [parents] that you can give the vaccine even as a birthday gift to that child.” Emphasis on sexuality, screening, and treatment before HPV vaccination The sexual history and outcome of HPV screening tests shape HPV vaccine administration in the clinic. The vaccinators delay sexually active adolescents until testing negative for HPV screening before vaccination. Omaama explained: [. . .] if this adolescent has confirmed that she has had sex [. . .] then the person has to wait until the age of 21 . . . and then the test will be carried out on this person. And if the person is tested negative, then the vaccine will be given to them. Youth or older people with a history of sexual practices require negative HPV test results before initiating the HPV vaccine series. Cordelia explained with an example that “let’s say she’s 25 and she’s sexually active, we need to screen that woman. And if she’s negative, then she qualifies to take the vaccine,” suggest ing positive results exclude those individuals from receiving HPV vaccination. Alison (vaccinator) expounded: If you are above [the] age [of] 20, 21 upwards and you are sexually active, you have to be tested. [. . .] We will test your HPV. We want to test your HPV but then when it’s negative, you can take the vaccine. When you are positive [for] any of them, we don’t advise you to take the vaccine. Theme 2: Attitudes towards HPV vaccination program and scale up Some vaccinators indicated that they were adequately prepared to provide HPV vaccination. Some program/policy leaders reported prioritizing acute care and infant and maternal mortal ity issues. Generally, some participants advocated for improving HPV vaccination, while some program/policy leaders indicated that HPV vaccination advocacy was not part of their job roles. Perceived preparedness for HPV vaccination Most vaccinators perceived they were adequately prepared in knowledge and scope to provide HPV vaccination in the clinic. Omaama explained: “So, you have to have all this knowledge about the vaccine before you would be allowed to [vaccinate]. So, I can say that [. . .], because I have received the training at this unit or facility, I am able to or I am allowed.” Yet, in explaining HPV vaccination preparedness, some vaccinators talked about cervical screening instead. Salamatu expounded: In school, [. . .] we were taught about this obstetric and medicine. We deal with women, [the] pelvis, and then the vulva, we were taught [. . .] how the vulva looks and all those things . . . so, like [. . .] from the knowledge I have, I think the human papillomavirus is usually hidden around the columnar epithelia junction [. . .]. So, with that, I’m able to use that to get more information . . . when you apply the acetic acid and . . . if it is negative too, you’re able to tell . . . based on that you can encourage the person to go in for the vaccine if she can. Focus on acute health concerns Some program/policy leaders acknowledged the benefits of HPV vaccination but indicated their current focus on acute health problems because of the perceived chronic nature of the HPV disease process. Dr Asaya explained: The burden of disease, as far as cervical cancer is concerned, is huge, the cost on households is huge . . . but it doesn’t come out very openly because [. . .] it doesn’t fall into the sphere of things [that] you define as maternal mortality . . . So, if a woman dies of cervical cancer, it’s not maternal mortality . . . It’s just a woman who has died . . . we have quite a whole number of reproductive health cancers and [. . .] HPV falls within that and these are chronic issues . . . So, now, as a country, where do you put your money for the greatest impact [. . .]? So, definitely, you would have to put it [to save] the mothers and not for chronic disease . . . Similarly, Dr Dominics discussed the rationale behind not prioritizing HPV vaccination for adolescent health programs. She explained: I’m right now taking care of [. . .] young people living with Type 1 Diabetes and for example, they need insulin to live and I’m trying to even get that to be taken care of by the NHIS . . . So it’s sort of yes, we do need immunizations for adolescents, [. . .] but for right now, I would say it is not my priority right now as pushing because even the insulin that is needed to live hasn’t been done. Advocacy for a publicly funded HPV program Most vaccinators advocated for interventions from the govern ment and non-governmental organizations to cover or subsi dize the vaccine cost to enhance accessibility. For instance, Salamatu suggested that “they should pass a law that every child must be vaccinated at the age of nine”. Other vaccinators reflected on a neighboring country’s approach and advocated the same for Ghana. Alison explained: . . . I feel that the question should have been the government coming to either help them with the HPV vaccine or give them for free [. . .] like what Nigeria is doing now. Nigeria just started giving HPV vaccines for free. Other vaccinators advocated for a publicly funded HPV vacci nation program using the approach for the COVID-19 vacci nation roll-out. Akwene explained: So, if the government should come in and we get a subsidized vaccine, it will help. We can recall when COVID-19 came and when the vaccines were made readily available, though a lot of people didn’t understand because of [a] knowledge deficit, [. . .] but the larger Ghanaian went for the vaccine. So, I’m sure that if the HPV vaccine is made available like the COVID-19 vaccine, people will come and vaccine. However, some program/policy leaders from the hospital reported that HPV vaccination advocacy was not part of their job roles. For instance, Dr Kwaa-Appiah indicated “I don’t make policies, so it’s difficult to speak to that [they] will tell you that there’s no money” whereas Dr Anokyewaa similarly described her job roles when 8 E. MARFO ET AL. asked about how to incorporate HPV vaccination into the national immunization program: I’m at the Ghana Health Services, an implementing agency. So, once it’s implemented why not as a facility-level public health physician? I will definitely be glad and follow guidelines and do as I’m told so again, I hit it again that I am not the policy formulator, I’m sure they know what they are doing up there, I am just under an implementing agency. Theme 3: Clinic operational barriers Identified HPV clinic operational barriers include vaccine unavailability and shortages. Vaccinators indicated they are challenged to rely on personal learning initiatives and resources to update themselves on HPV vaccination, as there are no formal educational programs for ongoing vaccination knowledge development. HPV vaccine shortage and unavailability Vaccinators discussed vaccine unavailability and intermit tent vaccine shortages as a key obstacle to HPV vaccina tion in the clinic. According to Cordelia, “It got to a point, we couldn’t get anything in the whole country”. These vaccine shortages contribute to a delay in vaccine uptake or hesitancy among some individuals financially capable of paying for their vaccination. Omaama recounted: I would say that a lot of people at the time they walked in to come and take the vaccination, [. . .] actually had the money with them. However, due to maybe [a] delay or if the vaccine is not in stock, sometimes, some of them don’t come back again . . . Furthermore, the HPV vaccine shortages contribute to incomplete vaccine series among some recipients. Salamatu explained that “Somebody can even start and they may not get the vaccine supplied, and so as a result cannot complete the series.” Vaccinators reported that the hospital does not supply HPV vaccines for the program anymore. Akwene indicated that: “the vaccine directly doesn’t come from the hospital” while other vaccinators spoke about the HPV vac cination program being the clinic’s initiative to support their clients. Asantewaa elaborated, “It’s not the hospital who is funding it [HPV vaccination] or the source is not from the hospital. It’s just a unit that is trying to help our clients out.” As a result, the vaccinators rely on third parties or private individuals to get HPV vaccines supplied to the clinic. However, other vaccinators perceived that the vaccine cost may be affordable if the hospital procures and supplies it. Akwene explained: . . . it is better [if] it’s home and then I think the price might come down [. . .] because there was a shortage sometime because of the COVID [. . .] so we had to rely on elsewhere . . . and it was like three times the price that we were giving to our clients [. . .] so, I assumed that if the hospital was to be providing it, there may be some subsidy on it and a lot of our clients can afford it. However, challenges with procuring the vaccines were reported to be the reasons behind the hospital’s inability to supply the vaccines to the clinic. Zen (Head of Pharmacy) explained that “there are certain times where you even tender and no one will even bid for it. So, it becomes a bit of a challenge even in terms of drug [vaccine] accessibility and availability to our client.” Lack of formal staff educational and training programs tailored to HPV vaccination Vaccinators indicated there are no formal or scheduled educa tional programs for updating their knowledge of HPV vacci nation. Salamatu explained: Not that I know of . . . there is not any program that has been organized on that [HPV vaccination]. We do most of the things [education] on our own . . . because the truth is we’ve never had any workshop that strictly talked about this HPV vaccine. Vaccinators highlighted they relied on several print and online resources for updates on current evidence for HPV vaccination. Alison explained: “We make sure we go to the internet, books, journals . . . and WHO has its own internet . . . when you go to the internet, WHO website, you should be able to get the information concerning cervical cancer” whereas Salamatu mentioned, “I go online, I read, I read more because there is always something new . . . sometimes I use Google and then YouTube as well.” Theme 4: Institutional challenges with HPV vaccination Institutional challenges include administrative and national health system barriers to HPV vaccination. The identified insti tutional challenges hindering HPV vaccination were a lack/dis interest in using HPV vaccination data for decision-making and ethical dilemmas about HPV vaccination policy-making. Lack and disuse of HPV vaccination data Some key vaccinators and program/policy leaders reported a lack of evidence on the benefits of the HPV vaccination program at the hospital. Dr Asaya indicated: Officially, we don’t know about it [HPV vaccination program at the Greater-Accra Regional Hospital], they will then have to reach a point and simply say, we think we have generated enough evidence, we think have generated enough to be able to make sure that . . . it [HPV vaccination] needs to be scaled-up. Dr Asaya further requested that the “facilities which are pilot ing or still carrying [out HPV vaccination] like Ridge [Greater- Accra Regional Hospital] then have to come out to simply say; what is the cost-effective way of doing it? What are the facilities involved?.” Yet, some vaccinators highlighted the lack of reporting on HPV vaccination data in the hospital. Asantewaa explained that “When we’re talking about vaccina tion [. . .], normally they use the CWC [Child Welfare Clinics] vaccination for their reports . . . This one [HPV vaccination], normally, we don’t use it for our report because the hospital is not providing the vaccine.” Ethical dilemmas about HPV vaccination policy-making Some program/policy leaders discussed ethical challenges sur rounding HPV vaccination in the context of limited resources and competing health priorities. Dr Asayah discussed that “as a country, definitely, our resources are very limited. And once you are drawing your national health policy, we would [. . .] have to simply focus on what normally has [a] greater impact for the greater part of the population.” They further argued: HUMAN VACCINES & IMMUNOTHERAPEUTICS 9 . . .If there’s a disease which is causing 30% of your mortality and somebody who causes 2% of mortality, where would you put your money? You would definitely put your money on the 30% [. . .]. But if you go in and deal with the 2%, you still have many more people dying or getting sick [. . .]. That’s why you find malaria gets more attention than anything else . . . A perceived threat to existing childhood immunization pro grams was indicated as one of the hindrances to HPV vaccina tion in Ghana. Dr Asayah discussed: . . . the existing Gavi program, we pay [a] counterpart, and we are supposed to by a certain time [. . .] be on our own, so what happens? So, this one [current EPI] you [Ghana] are still struggling to be on your own [and] you are bringing another one. Discussion In this study, we explored the current privately funded HPV vaccination program at the Greater-Accra Regional Hospital to identify program gaps, and to inform practice and national policy. This study relays crucial insights into several practice and policy challenges that shape the HPV vaccination program at the hospital. According to study participants, the current HPV vaccination program is operating without an established HPV vaccination policy, leading to reliance on convenient sources of information to guide practice. Despite collective advocacy for a publicly funded or subsidized HPV vaccination program among most vaccinators, there was reluctance in prioritizing and advocating for a publicly funded HPV vacci nation among some program/policy leaders due to threatened existing immunization programs, competing priorities with acute health problems, and ethical dilemmas with decision- making on HPV vaccination. We discuss our findings in more detail below, within the context of the literature. There were uncertainties whether a guiding policy existed. It may be that those vaccinators were unfamiliar with what an HPV vaccination policy is or wanted to shield the hospital out of fear of punitive consequences from superiors. Yet, a confirmatory interview with a national policymaker revealed the lack of an HPV vaccination policy, suggesting the need for one. A vaccination program without a policy can be limited in quality and efficiency, as there will be no accountability and sustainability measures.38 There is a need for consultation with key parties involved in HPV vaccination at all levels to meti culously develop an all-encompassing national and culturally aligned HPV vaccination policy that spells out awareness crea tion and sensitization mechanisms, provider education and accreditation strategies, eligibility criteria, appropriate delivery sites, and sustainability measures to ensure equitable access and vaccine delivery. In Ghana’s three-tier healthcare system, where preventive care and treatment of minor ailments occur at health centers and Community Health Planning and Services (CHPS) compounds,39 it would be ideal for healthcare providers in those settings to be involved in providing aware ness and education about HPV vaccination, even if not engaged in vaccination delivery. Furthermore, given how negotiation around HPV vaccination engagement is shaped by culture, agency, and structural influence, future research may investigate HPV vaccination perceptions and dynamics using the Culture-Centered Approach meta-theoretical framework.40 This study revealed that there are no routine educational programs to equip vaccinators with emerging evidence on HPV vaccination practice. Vaccinators mostly rely on self-led learning initiatives to support their HPV vaccination practices. These learning practices can lead to using non-credible infor mation or outdated evidence to inform vaccination practices, which may result in stagnant vaccination knowledge and prac tice skills. For instance, despite current evidence recommend ing that no HPV testing or screening is required before HPV vaccination,41 vaccinators reported rigid emphasis on having no history of sexual activity (i.e., the person has not been sexually active) or testing negative for HPV before HPV vac cination. This corresponds with findings from past studies about gaps in HPV vaccination knowledge among Ghanaian healthcare providers.7,14 Consequently, the clinic’s emphasis on sexual history and HPV vaccination screening contradicts current evidence,41,42 and mirrors the HPV-FASTER approach proposed specifically for Central and Eastern Europe, Latin America, Asia, and developed parts of Africa.43 Having HPV screening as a prerequisite for vaccination presents many practical challenges, particularly in terms of logistics and cost. For instance, the invasiveness of cervical examination and the additional cost or extra time in waiting for screening results before vaccination may discourage or delay the uptake of HPV vaccines by intended recipients. Given that HPV vaccination does not alter HPV disease treatment or follow- ups43 and individuals with HPV-positive results or cervical neoplasia may still benefit from vaccination protection against other HPV strains,44 we encourage that HPV vaccination is not delayed or refused for screening and treatment purposes among individuals seeking the vaccine. Similar to the vaccinators, HPV vaccination education and awareness programs for intended vaccine recipients are mostly opportunistic except for an annual cervical cancer awareness month program in January, where education and sensitization is maximized. These restricted educational approaches limit access to HPV vaccination information for individuals, most of whom may not have the privilege and intellectual abilities to search, identify, and interpret HPV vaccination information. Evidence shows adequate knowledge about HPV and HPV vaccination can maximize positive attitudes and intentions to receive HPV vaccination.45,46 In Ghana, where conservative cultural norms and perceived beliefs about sexuality and sexual health shape discussions and health-seeking behaviors about preventive health practices like HPV vaccination,7,13,47 there is a need for a concerted educational program tailored to max imizing awareness and benefits of HPV vaccines while demys tifying fallacies surrounding HPV vaccination to all stakeholders, including adolescents, parents, religious and community leaders, and teachers. Some program/policy leaders pointed out ethical dilem mas regarding HPV vaccination decision-making in the con text of competing health priorities, a national focus on minimizing maternal and infant mortality, and perceived threats to existing immunization programs due to interna tional funding cuts. For instance, a national policymaker questioned the population benefits of prioritizing HPV 10 E. MARFO ET AL. vaccination over causes of maternal and infant mortality. Although this utilitarian ethical approach to policymaking may serve the interest of much of the population,48 its applic ability leaves many practical questions. For example, one may argue about the value of saving a child under 5 years, only to have them die from a vaccine-preventable HPV-related can cer in adulthood. Hence, relying solely on utilitarian ethical principles to make decisions about HPV vaccination may impede a holistic assessment of HPV-related cancer problems and the appreciation of HPV vaccination programs’ benefits. There is compelling evidence on the cost-effectiveness of HPV vaccination in Ghana6 and similar contexts49–51 to be considered in addition to ethics and equity principles for HPV vaccination decision-making. Finally, most vaccinators felt adequately prepared to pro vide HPV vaccination and advocated for the involvement of government and non-governmental agencies to revamp the HPV vaccination program. They suggested that Ghana learns from neighboring Nigeria’s “one dose at a time” HPV vacci nation program52 or replicate the approaches for the success ful COVID-19 vaccination roll-out, corresponding with findings by the International Vaccine Access Center.53 Sadly, some program/policy leaders were reluctant to advo cate for HPV vaccination program investment, which is con sistent with a Chinese study which found no advocates for HPV vaccination at the local level.54 A salient step toward an HPV vaccination policy is creating awareness of the vaccina tion benefits.53 This requires a collective effort by all stake holders and agencies, including policymakers, clinicians, health professional associations and colleges, and researchers, to create a political will to obtain the government’s commitment.54 Strengths and limitations A strength of this study is being the first to explore the challenges in a privately funded HPV vaccination program in Ghana to inform practice and policy for the pending publicly funded program. The conceptualization of the study using an intersectionality theory, a North American Black Feminist scholarship, expanded the understanding of how system and structural factors shape HPV vaccination in limited-resource countries, like Ghana. The lessons from this study are transfer able to similar countries preparing to introduce publicly funded HPV vaccination programs. In terms of limitations, the sample size for this study was small due to the temporal and spatial boundaries of the case and the unavailability of some program/policy leaders. However, we recruited all HPV vaccinators at the hospital. As a qualitative study, we did not aspire to generalize findings. However, the study contributes evidence that may be transferable to similar contexts through adoption and adaption, given the description of the program context and participants’ demographics.55 Conclusion and recommendations This qualitative case study explored the Greater-Accra Regional Hospital’s HPV vaccination program to under stand the gaps and challenges and gather lessons to inform practice and policy. According to study participants, the HPV vaccination program at the hospital has no policy, and vaccinators rely on convenient sources of information to guide their practice. In contrast with current evidence, there is a common practice for HPV testing and cervical cancer screening for sexually active individuals before receiving HPV vaccination. Some program/policy leaders demonstrated reluctance in advocating for the program, describing advocacy as not part of their job roles, and citing ethical dilemmas in decision-making and competing health priorities as reasons. Based on these findings, we recommend that the hospital and other contexts with simi lar HPV vaccination programs adopt and adapt standar dized guidelines to support evidence-based vaccination practice. There is a need for a collective effort in HPV vaccination advocacy to stimulate political and government interests toward policy and decision-making. Acknowledgments The authors would like to thank all study participants and the Greater-Accra Global Health Research Center staff for their role in conducting this study. We are thankful to the Applied Immunization Research Program staff and the Faculty of Nursing at the University of Alberta for supporting this research in kind. We are thankful to research assistant KD King for validating codes. Disclosure statement No potential conflict of interest was reported by the author(s). Funding This study was not funded by any agency. The first author received a graduate research international mobility award from the University of Alberta Faculty of Nursing in support of his dissertation research. Notes on contributor Emmanuel Marfo is a nursing PhD candidate at the Faculty of Nursing, University of Alberta. He works as a research assistant in the Applied Immunization Research Program (Aimm). Emmanuel’s research interests include equitable access and delivery of HPV vac cination, global health equity, and adolescent sexual and reproductive health. ORCID Emmanuel Marfo http://orcid.org/0000-0002-9654-404X Author contributions EAM was involved in conceptualization, investigation, formal analy sis, interpretation of findings and writing (original drafting, review, and editing). OOS, CAA, and SEM were involved in conceptualization, supervision and writing (review and editing). Code availability Codes and code descriptions are available in Table 2. HUMAN VACCINES & IMMUNOTHERAPEUTICS 11 Data availability statement To protect participants’ confidentiality and privacy, data and study mate rials are not deposited in any public or research repository. Consent to participate All participants provided written informed consent before participating in the study. Consent to publish All study participants were informed that research findings will be shared with the scientific community through peer-review journal publication. References 1. Guo J, Guo S, Dong S. Efficacy, immunogenicity and safety of HPV vaccination in Chinese population: a meta-analysis. Front Public Heal. 2023 [accessed 2024 Mar 27];11:1–13. doi:10.3389/fpubh. 2023.1128717 . 2. Lei J, Ploner A, Elfström KM, Wang J, Roth A, Fang F, Sundström K, Dillner J, Sparén P. HPV vaccination and the risk of invasive cervical cancer. N Engl J Med. 2020;383(14):1340–1348. doi:10.1056/nejmoa1917338 . 3. Kjaer SK, Dehlendorff C, Belmonte F, Baandrup L. Real-world effectiveness of human papillomavirus vaccination against cervical cancer. J Natl Cancer Inst. 2021;113(10):1329–1335. doi:10.1093/ jnci/djab080 . 4. GAVI. Ghana to vaccinate girls against HPV with GAVI support. 2024 [accessed 2024 Mar 27]. https://www.gavi.org/news/media- room/ghana-vaccinate-girls-against-hpv-gavi-support . 5. Nartey Y, Hill P, Amo-Antwi K, Asmah R, Nyarko K, Yarney J, Damale N, Cox B. Recommendations for cervical cancer preven tion and control in Ghana: public education and human papillo mavirus vaccination. Ghana Med J. 2018;52(2):94–102. doi:10. 4314/gmj.v52i2.6 . 6. Vodicka E, Nonvignon J, Antwi-Agyei KO, Bawa J, Clark A, Pecenka C, LaMontagne DS. The projected cost-effectiveness and budget impact of HPV vaccine introduction in Ghana. Vaccine. 2022;40:85–93. doi:10.1016/j.vaccine.2021.07.027 . 7. Agyei-Baffour P, Asare M, Lanning B, Koranteng A, Millan C, Commeh ME, Montealegre JR, Mamudu HM. Human papilloma virus vaccination practices and perceptions among Ghanaian healthcare providers: a qualitative study based on multitheory model. PLOS ONE. 2020 Oct;15(10):e0240657. doi:10.1371/jour nal.pone.0240657 . 8. National Health Insurance Authority. Benefits package. 2024. https://www.nhis.gov.gh/benefits . 9. United Nations. Nigeria to vaccinate 7.7 million girls against leading cause of cervical cancer. Published 2023 [accessed 2024 Apr 6]. https://unsdg.un.org/latest/stories/nigeria-vaccinate-77- million-girls-against-leading-cause-cervical-cancer . 10. TV3 News. Nationwide vaccination against human papilloma virus to begin by close of year – Ghana health service. 2024 [accessed 2024 Mar 27]. https://3news.com/health/nationwide- vaccination-against-human-papilloma-virus-to-begin-by-close-of -year-ghana-health-service/ . 11. Ampofo AG, Gyamfuaah SA, Opoku NS, Owusu SO, Ibitoye MB. A pilot study of a video-based educational intervention and knowl edge of cervical cancer among senior high school students in Ghana: a before-after study. J Cancer Policy. 2020;24:24. doi:10. 1016/j.jcpo.2020.100220 . 12. Osei EA, Appiah S, Gaogli JE, Oti-Boadi E. Knowledge on cervical cancer screening and vaccination among females at Oyibi Community. BMC Womens Health. 2021;21(1). doi:10.1186/ s12905-021-01296-3 . 13. Asare M, Agyei-Baffour P, Lanning BA, Barimah Owusu A, Commeh ME, Boozer K, Koranteng A, Spies LA, Montealegre JR, Paskett ED, et al. Multi-theory model and pre dictors of likelihood of accepting the series of HPV vaccination: a cross-sectional study among Ghanaian adolescents. Int J Environ Res Public Health. 2020;17(2):571. doi:10.3390/ijerph17020571 . 14. Ebu NI, Abotsi-Foli GE, Gakpo DF. Nurses’ and midwives’ knowl edge, attitudes, and acceptance regarding human papillomavirus vaccination in Ghana: a cross-sectional study. BMC Nurs. 2021;20 (1). doi:10.1186/s12912-020-00530-x . 15. Wilson R. HPV vaccine acceptance in West Africa: a systematic literature review. Vaccine. 2021;39(37):5277–5284. doi:10.1016/j. vaccine.2021.06.074 . 16. Drokow EK, Zi L, Han Q, Effah CY, Agboyibor C, Sasu E, Akpabla GS, Foli F, Sun K. Awareness of cervical cancer and attitude toward human papillomavirus and its vaccine among ghanaians. Front Oncol. 2020;10:10. doi:10.3389/fonc.2020.01651 . 17. Coleman MA, Levison J, Sangi-Haghpeykar H. HPV vaccine acceptability in Ghana, West Africa. Vaccine. 2011;29 (23):3945–3950. doi:10.1016/j.vaccine.2011.03.093 . 18. Ampofo AG, Mackenzie L, Boyes AW. HPV vaccination: intention to participate among female senior high school students in Ghana. Vaccine. 2023;41(1):159–169. doi:10.1016/j.vaccine.2022.11.007 . 19. Asare M, Agyei-Baffour P, Koranteng A, Commeh ME, Fosu ES, Elizondo A, Sturdivant RX. Assessing the efficacy of the 3R (reframe, reprioritize, and reform) communication model to increase HPV vaccinations acceptance in Ghana: community-based intervention. Vaccines. 2023;11(5):890. doi:10. 3390/vaccines11050890 . 20. Yin RK. Case study research and applications design and methods. 6th ed. United States of America: SAGE Publications; 2018. 21. Salzmann-Erikson M. The intersection between logical empiricism and qualitative nursing research: a post-structuralist analysis. Int J Qual Stud Health Well-Being. 2024;19(1). doi:10.1080/ 17482631.2024.2315636 . 22. Crenshaw K. Demarginalizing the intersection of race and sex: a black feminist critique of antidiscrimination doctrine, feminist theory and antiracist politics. Univ Chic Leg Forum. 1989;8 (1):1–31. http://chicagounbound.uchicago.edu/uclfhttp://chica gounbound.uchicago.edu/uclf/vol1989/iss1/8 . 23. Carastathis A. The concept of intersectionality in feminist theory. Philos Compass. 2014;9(5):304–314. doi:10.1111/phc3.12129 . 24. Branković I, Verdonk P, Klinge I. Applying a gender lens on human papillomavirus infection: cervical cancer screening, HPV DNA testing, and HPV vaccination. Int J Equity Health. 2013;12 (1):14. doi:10.1186/1475-9276-12-14 . 25. Kornides M, Head KJ, Feemster K, Zimet GD, Panozzo CA. Associations between HPV vaccination among women and their 11–14-year-old children. Hum Vaccines Immunother. 2019;15(7– 8):1824–1830. doi:10.1080/21645515.2019.1625642 . 26. Smolarczyk K, Duszewska A, Drozd S, Majewski S. Parents’ knowl edge and attitude towards HPV and HPV vaccination in Poland. Vaccines. 2022;10(2):228. doi:10.3390/vaccines10020228 . 27. Palinkas LA, Horwitz SM, Green CA, Wisdom JP, Duan N, Hoagwood K. Purposeful sampling for qualitative data collection and analysis in mixed method implementation research. Adm Policy Ment Heal Ment Heal Serv Res. 2015;42(5):533–544. doi:10.1007/s10488-013-0528-y . 28. Chicoine G, Côté J, Pepin J, Boyer L, Rouleau G, Jutras-Aswad D. Experiences and perceptions of nurses participating in an inter professional, videoconference-based educational programme on concurrent mental health and substance use disorders: a qualitative study. BMC Nurs. 2022;21(1). doi:10.1186/s12912- 022-00943-w . 29. Braun V, Clarke V. To saturate or not to saturate? Questioning data saturation as a useful concept for thematic analysis and sample-size rationales. Qual Res Sport Exerc Heal. 2021;13 (2):201–216. doi:10.1080/2159676X.2019.1704846 . 30. Gale NK, Heath G, Cameron E, Rashid S, Redwood S. Using the framework method for the analysis of qualitative data in 12 E. MARFO ET AL. https://doi.org/10.3389/fpubh.2023.1128717 https://doi.org/10.3389/fpubh.2023.1128717 https://doi.org/10.1056/nejmoa1917338 https://doi.org/10.1093/jnci/djab080 https://doi.org/10.1093/jnci/djab080 https://www.gavi.org/news/media-room/ghana-vaccinate-girls-against-hpv-gavi-support https://www.gavi.org/news/media-room/ghana-vaccinate-girls-against-hpv-gavi-support https://doi.org/10.4314/gmj.v52i2.6 https://doi.org/10.4314/gmj.v52i2.6 https://doi.org/10.1016/j.vaccine.2021.07.027 https://doi.org/10.1371/journal.pone.0240657 https://doi.org/10.1371/journal.pone.0240657 https://www.nhis.gov.gh/benefits https://unsdg.un.org/latest/stories/nigeria-vaccinate-77-million-girls-against-leading-cause-cervical-cancer https://unsdg.un.org/latest/stories/nigeria-vaccinate-77-million-girls-against-leading-cause-cervical-cancer https://3news.com/health/nationwide-vaccination-against-human-papilloma-virus-to-begin-by-close-of-year-ghana-health-service/ https://3news.com/health/nationwide-vaccination-against-human-papilloma-virus-to-begin-by-close-of-year-ghana-health-service/ https://3news.com/health/nationwide-vaccination-against-human-papilloma-virus-to-begin-by-close-of-year-ghana-health-service/ https://doi.org/10.1016/j.jcpo.2020.100220 https://doi.org/10.1016/j.jcpo.2020.100220 https://doi.org/10.1186/s12905-021-01296-3 https://doi.org/10.1186/s12905-021-01296-3 https://doi.org/10.3390/ijerph17020571 https://doi.org/10.1186/s12912-020-00530-x https://doi.org/10.1016/j.vaccine.2021.06.074 https://doi.org/10.1016/j.vaccine.2021.06.074 https://doi.org/10.3389/fonc.2020.01651 https://doi.org/10.1016/j.vaccine.2011.03.093 https://doi.org/10.1016/j.vaccine.2022.11.007 https://doi.org/10.3390/vaccines11050890 https://doi.org/10.3390/vaccines11050890 https://doi.org/10.1080/17482631.2024.2315636 https://doi.org/10.1080/17482631.2024.2315636 http://chicagounbound.uchicago.edu/uclfhttp://chicagounbound.uchicago.edu/uclf/vol1989/iss1/8 http://chicagounbound.uchicago.edu/uclfhttp://chicagounbound.uchicago.edu/uclf/vol1989/iss1/8 https://doi.org/10.1111/phc3.12129 https://doi.org/10.1186/1475-9276-12-14 https://doi.org/10.1080/21645515.2019.1625642 https://doi.org/10.3390/vaccines10020228 https://doi.org/10.1007/s10488-013-0528-y https://doi.org/10.1186/s12912-022-00943-w https://doi.org/10.1186/s12912-022-00943-w https://doi.org/10.1080/2159676X.2019.1704846 multi-disciplinary health research. BMC Med Res Methodol. 2013;13(1):117. doi:10.1186/1471-2288-13-117 . 31. Knott E, Rao AH, Summers K, Teeger C. Interviews in the social sciences. Nat Rev Methods Prim. 2022;2(1). doi:10.1038/s43586- 022-00150-6 . 32. Croni C. Using case study research as a rigorous form of inquiry. Nurse Res. 2014;21(5):19–27. doi:10.7748/nr.21.5.19.e1240 . 33. Atkins L, Francis J, Islam R, O’Connor D, Patey A, Ivers N, Foy R, Duncan EM, Colquhoun H, Grimshaw JM, et al. A guide to using the theoretical domains framework of behaviour change to inves tigate implementation problems. Implement Sci. 2017;12(1). doi:10.1186/s13012-017-0605-9 . 34. Gallant AJ, Johnson C, Steenbeek A, Parsons Leigh J, Halperin SA, Curran JA. Stakeholders’ experiences with school-based immuni zation programs during the COVID-19 pandemic in the Canadian maritimes: a qualitative study. Public Heal Pract. 2024;7:7. doi:10. 1016/j.puhip.2024.100505 . 35. Rowlands S, Tariq A, Coverdale S, Walker S, Wood M. A qualitative investigation into clinical documentation: why do clinicians document the way they do? Heal Inf Manag J. 2022;51 (3):126–134. doi:10.1177/1833358320929776 . 36. Birt L, Scott S, Cavers D, Campbell C, Walter F. Member checking: a tool to enhance trustworthiness or merely a nod to validation? Qual Health Res. 2016;26(13):1802–1811. doi:10.1177/1049732316654870 . 37. O’Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for reporting qualitative research: a synthesis of recommendations. Acad Med. 2014;89(9):1245–1251. doi:10. 1097/ACM.0000000000000388 . 38. Anderson EL. Recommended solutions to the barriers to immu nization in children and adults center for vaccine development. Mo Med. 2014;111(4):344–348. www.cdc.gov/vaccines/vac-en /6mishome . 39. Arhin K, Oteng-Abayie EF, Novignon J. Cost efficiency of primary health care facilities in Ghana: stochastic frontier analysis. Discov Heal Syst. 2023;2(1). doi:10.1007/s44250-023-00044-8 . 40. Dutta MJ. Culture-centered approach in addressing health dispa rities: communication infrastructures for subaltern voices. Commun Methods Meas. 2018;12(4):239–259. doi:10.1080/ 19312458.2018.1453057 . 41. Centers for Disease Control and Prevention. HPV vaccine infor mation for young women. 42. Cox TJ, Palefsky JM. Human papillomavirus vaccination. UpToDate. Published 2024. https://www.uptodate.com/contents/ human-papillomavirus-vaccination/printwww.uptodate.com . 43. Bosch FX, Robles C, Díaz M, Arbyn M, Baussano I, Clavel C, Ronco G, Dillner J, Lehtinen M, Petry K-U, et al. HPV-FASTER: broadening the scope for prevention of hpv-related cancer. Nat Rev Clin Oncol. 2016;13(2):119–132. doi:10.1038/nrclinonc. 2015.146 . 44. National Advisory Committee on Immunization (NACI). Updated recommendations on human papillomavirus (HPV) vaccines: 9-valent HPV vaccine and clarification of minimum intervals between doses in the HPV immunization schedule. 2017 [accessed 2024 Mar 27]. https://www.canada.ca/content/dam/hc- sc/healthy-canadians/migration/publications/healthy-living-vie- saine/human-papillomavirus-9-valent-vaccine-update- recommendation-mises-a-jour-recommandations-papillome- humain-vaccin-nonavalent/alt/hpv-phv-eng.pdf . 45. Ramezankhani A, Bahrambeygi F. Educational interventions planned to increase human papillomavirus vaccination acceptance among adolescents and their parents in Asia: a systematic litera ture review. J Prev Diagnostic Treat Strateg Med. 2024;3(1):27–36. doi:10.4103/jpdtsm.jpdtsm_136_23 . 46. Zurales KR, Appiah‐Kubi A, Bell SG, Konney T, Tawiah A, Kobernik EK, Lawrence ER. Attitudes and knowledge about HPV vaccination among Ghanaian women with cervical cancer. Reprod Female Child Heal. 2023;2(1):11–18. doi:10.1002/rfc2.24 . 47. Popelsky BK, Asare M, Agyei-Baffour P, Koranteng A, Commeh ME. Assessing attitudes and beliefs toward HPV vacci nation among Ghanaian parents with unvaccinated adolescents: application of multi-theory model of behavior change. Asian Pac J Cancer Prev. 2022;23(6):1901–1911. doi:10.31557/APJCP.2022. 23.6.1901 . 48. Savulescu J, Persson I, Wilkinson D. Utilitarianism and the pandemic. Bioethics. 2020;34(6):620–632. doi:10.1111/bioe.12771 . 49. Fesenfeld M, Hutubessy R, Jit M. Cost-effectiveness of human papillomavirus vaccination in low and middle income countries: a systematic review. Vaccine. 2013;31(37):3786–3804. doi:10.1016/ j.vaccine.2013.06.060 . 50. Aguilar IBM, Mendoza LO, García O, Díaz I, Figueroa J, Duarte RM, Perdomo G, Garcia AGF, Janusz CB. Cost- effectiveness analysis of the introduction of the human papilloma virus vaccine in honduras. Vaccine. 2015;33(S1):167–173. doi:10. 1016/j.vaccine.2014.12.067 . 51. Silas OA, Achenbach CJ, Murphy RL, Hou L, Sagay SA, Banwat E, Adoga AA, Musa J, French DD. Cost effectiveness of human papilloma virus vaccination in low and middle income countries: a systematic review of literature. Expert Rev Vaccines. 2018;17 (1):91–98. doi:10.1080/14760584.2018.1411195 . 52. International Vaccine Access Center (IVAC). One dose at a time: mobilizing to eliminate cervical cancer in Nigeria. Published 2024. https://publichealth.jhu.edu/ivac/2024/one . 53. International Vaccine Access Center (IVAC). HPV vaccine pro gress and next steps for advocacy in Ghana: findings from key informants. 2023 [accessed 2024 Mar 27]. https://publichealth.jhu. edu/sites/default/files/2024-02/hpv-vaccine-advocacy-in- ghanaivac2023ax.pdf . 54. Chen R, Wong E. The feasibility of universal HPV vaccination program in Shenzhen of China: a health policy analysis. BMC Public Health. 2019;19(1). doi:10.1186/s12889-019-7120-7 . 55. Stalmeijer RE, Brown MEL, O’Brien BC. How to discuss transfer ability of qualitative research in health professions education. Clin Teach. Published online 2024; doi:10.1111/tct.13762. HUMAN VACCINES & IMMUNOTHERAPEUTICS 13 https://doi.org/10.1186/1471-2288-13-117 https://doi.org/10.1038/s43586-022-00150-6 https://doi.org/10.1038/s43586-022-00150-6 https://doi.org/10.7748/nr.21.5.19.e1240 https://doi.org/10.1186/s13012-017-0605-9 https://doi.org/10.1016/j.puhip.2024.100505 https://doi.org/10.1016/j.puhip.2024.100505 https://doi.org/10.1177/1833358320929776 https://doi.org/10.1177/1049732316654870 https://doi.org/10.1097/ACM.0000000000000388 https://doi.org/10.1097/ACM.0000000000000388 http://www.cdc.gov/vaccines/vac-en/6mishome http://www.cdc.gov/vaccines/vac-en/6mishome https://doi.org/10.1007/s44250-023-00044-8 https://doi.org/10.1080/19312458.2018.1453057 https://doi.org/10.1080/19312458.2018.1453057 https://www.uptodate.com/contents/human-papillomavirus-vaccination/printwww.uptodate.com https://www.uptodate.com/contents/human-papillomavirus-vaccination/printwww.uptodate.com https://doi.org/10.1038/nrclinonc.2015.146 https://doi.org/10.1038/nrclinonc.2015.146 https://www.canada.ca/content/dam/hc-sc/healthy-canadians/migration/publications/healthy-living-vie-saine/human-papillomavirus-9-valent-vaccine-update-recommendation-mises-a-jour-recommandations-papillome-humain-vaccin-nonavalent/alt/hpv-phv-eng.pdf https://www.canada.ca/content/dam/hc-sc/healthy-canadians/migration/publications/healthy-living-vie-saine/human-papillomavirus-9-valent-vaccine-update-recommendation-mises-a-jour-recommandations-papillome-humain-vaccin-nonavalent/alt/hpv-phv-eng.pdf https://www.canada.ca/content/dam/hc-sc/healthy-canadians/migration/publications/healthy-living-vie-saine/human-papillomavirus-9-valent-vaccine-update-recommendation-mises-a-jour-recommandations-papillome-humain-vaccin-nonavalent/alt/hpv-phv-eng.pdf https://www.canada.ca/content/dam/hc-sc/healthy-canadians/migration/publications/healthy-living-vie-saine/human-papillomavirus-9-valent-vaccine-update-recommendation-mises-a-jour-recommandations-papillome-humain-vaccin-nonavalent/alt/hpv-phv-eng.pdf https://www.canada.ca/content/dam/hc-sc/healthy-canadians/migration/publications/healthy-living-vie-saine/human-papillomavirus-9-valent-vaccine-update-recommendation-mises-a-jour-recommandations-papillome-humain-vaccin-nonavalent/alt/hpv-phv-eng.pdf https://doi.org/10.4103/jpdtsm.jpdtsm_136_23 https://doi.org/10.1002/rfc2.24 https://doi.org/10.31557/APJCP.2022.23.6.1901 https://doi.org/10.31557/APJCP.2022.23.6.1901 https://doi.org/10.1111/bioe.12771 https://doi.org/10.1016/j.vaccine.2013.06.060 https://doi.org/10.1016/j.vaccine.2013.06.060 https://doi.org/10.1016/j.vaccine.2014.12.067 https://doi.org/10.1016/j.vaccine.2014.12.067 https://doi.org/10.1080/14760584.2018.1411195 https://publichealth.jhu.edu/ivac/2024/one https://publichealth.jhu.edu/sites/default/files/2024-02/hpv-vaccine-advocacy-in-ghanaivac2023ax.pdf https://publichealth.jhu.edu/sites/default/files/2024-02/hpv-vaccine-advocacy-in-ghanaivac2023ax.pdf https://publichealth.jhu.edu/sites/default/files/2024-02/hpv-vaccine-advocacy-in-ghanaivac2023ax.pdf https://doi.org/10.1186/s12889-019-7120-7 https://doi.org/10.1111/tct.13762 Abstract Introduction Materials and methods Research design and theoretical approach Researcher characteristics and reflexivity Study setting Sampling strategy Ethics approval Data collection methods and tools Data analysis and rigour Results Participant characteristics Overview of interview findings  Theme 1: Current clinic operations and vaccinationprocesses Uncertainty about existing policy for HPV vaccination Strategies for HPV vaccine recipient education Emphasis on sexuality, screening, and treatment before HPV vaccination Theme 2: Attitudes towards HPV vaccination program and scale up Perceived preparedness for HPV vaccination Focus on acute health concerns Advocacy for a publicly funded HPV program Theme 3: Clinic operational barriers HPV vaccine shortage and unavailability Lack of formal staff educational and training programs tailored to HPV vaccination Theme 4: Institutional challenges with HPV vaccination Lack and disuse of HPV vaccination data Ethical dilemmas about HPV vaccination policy-making Discussion Strengths and limitations Conclusion and recommendations Acknowledgments Disclosure statement Funding Notes on contributor ORCID Author contributions Code availability Data availability statement Consent to participate Consent to publish References