# Facilitators and barriers to implementation of HPV vaccination in Tanzania: a mixed-methods study exploring perspectives from national, subnational, and community stakeholders, 2018–2023

## TL;DR

This study explores what helped and hindered HPV vaccination in Tanzania, offering insights to improve vaccine coverage and support global cervical cancer elimination.

## Contribution

The study provides a mixed-methods analysis of HPV vaccine implementation in Tanzania, identifying context-specific facilitators and barriers.

## Key findings

- Political support and integration with existing systems contributed to high HPV vaccine coverage in Tanzania.
- Funding gaps, staff shortages, and poor sector coordination were major barriers to program success.
- Stakeholders recommended increased funding, cross-sector collaboration, and community engagement to improve implementation.

## Abstract

Cervical cancer is the fourth most common cancer among women globally, disproportionately affecting those in low- and middle-income countries (LMICs). In 2020, World Health Organization (WHO) Member States endorsed the 2030 Global Strategy toward Elimination of Cervical Cancer, recommending expanded access to human papillomavirus (HPV) vaccination. However, gaps remain in understanding how LMICs can sustain high HPV vaccine coverage. Tanzania, an early adopter among LMICs, introduced HPV vaccination into the national immunization schedule for 14-year-old girls in 2018 and achieved >90 % two-dose coverage by 2023. This study evaluated HPV vaccine program implementation in Tanzania, capturing stakeholder perspectives on barriers, facilitators, and recommendations.

Stakeholders were interviewed in April 2024 in a concurrent mixed-methods evaluation. Participants included national and subnational immunization staff (n = 18), and health workers, teachers, and community influencers (n = 80). Four of 31 regions were purposively selected based on criteria including first-dose HPV coverage (2020–2022) and urban/rural distribution. Two health facilities were randomly selected from a list of facilities in each region, along with two schools administering the vaccine from each facility’s catchment area. Quantitative data were analyzed descriptively in STATA v.18, and qualitative data analyzed in ATLAS.ti Web (v19.3.1).

Political support, quality improvement cycles, and integration with existing systems were identified as contributing to program success. Funding gaps and staff shortages–particularly in regions with low HPV vaccination coverage–were among the reported barriers, along with poor coordination between health and education sectors and low community awareness. Recommendations included increasing government funding, strengthening cross-sector collaboration, training stakeholders, and expanding dissemination channels to improve demand and address vaccine hesitancy.

Tanzania’s experience offers lessons for HPV vaccination in similar contexts. Addressing key barriers through increased funding, improved coordination, and enhanced community engagement could improve HPV vaccination implementation in Tanzania and elsewhere, contributing to global cervical cancer elimination.