In May 2018, the Government of Zimbabwe Ministry of Health, in collaboration with the Ministry of Education, introduced the HPV vaccine nationwide following a successful pilot program in two districts [1,2]. In accordance with the World Health Organization (WHO) recommendations, the campaign targeted multiple cohorts during the first year of the introduction for the greatest public health impact [3]. The primarily school-based campaign targeted all girls aged 10–14 years with the first dose of the HPV vaccine. The second dose was administered to this cohort one year later, concurrently with a first dose being administered to a new single cohort of all grade 5 girls in-school and out-of-school girls aged 10 years [4]. From 2020 onward, the single cohort (grade 5 girls in-school and out-of-school girls aged 10 years) will receive the first dose annually at the same time as the previous cohort’s second dose.

The first vaccination campaign in May 2018 achieved 83% administrative coverage for the first dose targeting multiple cohorts [5] through primarily school-based vaccination sessions taking place over one week. According to WHO/United Nations International Children’s Emergency Fund (UNICEF) estimates, the second vaccination campaign in May 2019 achieved 67% coverage for the second dose of the multiple cohort and 91% coverage for the first dose of the single cohort [5]. Both campaigns were carried out by teams of health workers in partnership with school health coordinators (teachers from each school trained in basic health topics); village health workers helped identify out-of-school girls [4,6]. A stand-alone training was provided to health workers, school health coordinators and village health workers prior to the 2018 campaign only. Eligibility for vaccination was determined by school health coordinators and health workers, using the information on grade, current age, or birth year. Strong political commitment and good cooperation between the health and education sectors contributed to high administrative coverage; however, challenges with transitioning between cohorts, funding shortages, and concerns about sustainability were reported [30].

Evaluating program feasibility, assessing knowledge of HPV and the HPV vaccine, and understanding community and stakeholder acceptability can support program improvements to maintain community demand and improve vaccine uptake. We conducted feasibility and acceptability surveys among health workers, school personnel, and community members to understand their perceptions of community awareness, implementation, training, and social mobilization. Lessons, best practices, and challenges from the community-level can inform the programmatic success of Zimbabwe’s HPV vaccination program in the future. Experiences in Zimbabwe, a resource-constrained and complex environment with economic, infrastructure, and healthcare access challenges, may be useful for HPV vaccine introduction planning in similar settings.

Cross-sectional surveys were administered to health workers, school health coordinators, village health workers, and community leaders in January and February 2020. The surveys took place after two HPV vaccination campaigns were completed in Zimbabwe, in May 2018 and May 2019.

The HPV vaccine introduction in Zimbabwe was effective at reaching large numbers of eligible girls with 751,367 doses delivered in the 2018 campaign and 801,887 doses delivered in the 2019 campaign, as reported through the WHO/UNICEF joint reporting process [8]. The HPV vaccine introduction was considered a success by the national-level stakeholders due to political commitment, strong collaborations, and careful preparation [30]. In our evaluation conducted at the health facility and community level, respondents identified funding gaps, lack of transportation, and staff shortages as key challenges faced in the implementation of the HPV vaccination program.

The extended and complex economic situation in Zimbabwe, exacerbated by Cyclone Idai in March 2019 and a severe drought, has led to numerous downstream effects, including inflated prices of goods, limited fuel availability, decreased access to electricity and water, and increased food insecurity [9]. Infrastructure challenges, supply stockouts, and staffing shortages have negatively impacted access to health services and patient care [10]. Despite these complicated obstacles, health workers found the HPV vaccine delivery feasible and the program was well accepted by the school and community respondents. Prioritizing sustained funding for the HPV vaccination in Zimbabwe will help maintain gains achieved in the HPV vaccination so far and will contribute to a sustainable future for the program.

School-based vaccination has been shown to result in high coverage, and programs incorporating health facility vaccination into this strategy have shown most effective at reaching the target population [11-14]. Findings support that the school-based campaign was feasible and well-accepted in Zimbabwe. Despite some challenges identified, health workers and teachers were well informed about the HPV vaccination program and indicated having the capacity to deliver services to the target population while maintaining routine immunization services. This suggests school-based HPV vaccination in similar low-resource settings is possible, provided necessary funding is available. Moving forward, reaching out-of-school girls through engagement with the community health workers or by using other strategies will ensure equity in the HPV vaccination program in Zimbabwe.

The introduction of the HPV vaccine presents an opportunity for many low- and middle-income country immunization programs to target a population that is not typically reached by routine immunization services. Questions remain as to the ideal target group selection for the HPV vaccination, and the decision is largely based on country preference and context. While Zimbabwe achieved high coverage (83%) in the initial age-based HPV vaccination of a multiple cohort, findings from this survey illustrate that the transition from the 10–14-year-old age-based multiple cohort to the grade 5 single cohort was not well understood among the respondents. Improper identification of eligible girls can lead to missed opportunities for vaccination, vaccination outside the target group, or inaccuracies in recording and reporting—potentially resulting in coverage inaccuracies. Further, different criteria for in-school girls (grade-based) and out-of-school girls (age-based) can lead to additional confusion among health workers and the community. As Zimbabwe continues the HPV vaccination program with grade-based, primarily in-school vaccination, this confusion is likely to reduce; however, the continuation of trainings and communication to the public on eligibility is essential.

Nearly half of the respondents in the survey reported having heard negative rumors related to the HPV vaccine. Concerns about the HPV vaccine possibly causing severe side effects or having a negative effect on future fertility have commonly been reported during the HPV vaccine introductions elsewhere [15]. Vaccine hesitancy has been reported in pockets of the population in Zimbabwe, primarily among religious groups [16-18]. Fortunately, overall high coverage for the HPV vaccination has been seen in the administrative records and a coverage survey [6,19] suggesting that rumors have not negatively impacted vaccine uptake thus far. However, Zimbabwe should monitor these rumors and work to maintain community acceptability as vaccine hesitancy and rumors have derailed the HPV vaccination programs in other countries [20-23]. Continued training and sensitization around rumor management as well as maintenance of a risk communication plan will be important in the coming years, especially as access to the internet, social media, and other information sources become more widespread in Zimbabwe.

Coverage for the HPV vaccination programs is higher in low- and middle-income countries when compared to high-income countries [13]. Vaccination programs are often well-trusted in low-resource settings where the impact of vaccines has been seen with the reduction of vaccine-preventable diseases over time [24,25]. Low hesitancy and good uptake of the HPV vaccine has been observed in resource-constrained settings where the burden of cervical cancer is often high and screening and treatment capabilities are limited [25-27]. Survey respondents from all groups considered cervical cancer to be a very serious disease, which is consistent with previous reports by health workers of concerns related to cervical cancer among young people and the presence of general support for the HPV vaccination programs in Zimbabwe [28,29]. Almost all respondents felt that receiving the HPV vaccine is important; additionally, village health workers and community leaders indicated a high level of acceptance in their communities.

There are several limitations to this survey. Within each health facility catchment area, one school health coordinator, one village health worker, and one community leader were selected, using convenience sampling by the data collection team. While this allowed for the selection of stakeholders from a range of geographic and urban/rural communities, it was not random. Health workers assisted in the referral of nearby individuals available for interviews at the time of the visit, and they may have recommended respondents more familiar with and knowledgeable about the HPV program.

All questionnaires were written and displayed on tablets in English. While Shona and Ndebele translations were available within the tablet interface for data collectors for village health worker and community leader questionnaires, variability in the interpretation of specific questions within the survey is possible. Lastly, the survey was administered more than one year after the vaccine was introduced; therefore, participants may have had difficulty recalling experiences related to certain questions pertaining directly to the introduction period.

Findings from this survey supported evidence of a strong nationwide HPV vaccine introduction in Zimbabwe. It was feasible for the health system to implement and was well accepted within the community. Challenges in determining target eligibility were seen within the first year of introduction and the lack of full understanding of the target eligibility criteria may have led to missed opportunities for vaccination, vaccinating outside the target group, and recording and reporting challenges. The Zimbabwe immunization program should strive to maintain gains achieved so far, continue fostering high demand for the HPV vaccine and advocate for additional resources from the government, partners, and donors to ensure the sustainability of the HPV program in the future.