Protect her future: Lessons learned from a school and community engagement initiative for HPV vaccine awareness in Lilongwe, Malawi

ABSTRACT

Human papillomavirus (HPV) vaccination is an effective strategy for preventing cervical cancer, yet vaccine uptake in Malawi remains low because of misinformation, limited awareness, and parental hesitancy. This study describes the implementation of a youth-led school and community engagement initiative to promote HPV vaccine awareness in Lilongwe, Malawi, and highlights lessons for future immunization programs. We conducted a descriptive implementation case study of a two-day youth-led engagement initiative coordinated by fellows of the 2025–2026 Global Health Corps Malawi Leadership Accelerator in collaboration with the Lilongwe District Health Office, Kawale Primary School, and partner organizations. Activities included stakeholder meetings, school health education, myth-busting sessions, learner-centered activities, community dialogs, distribution of educational materials, and on-site HPV vaccination services. Girls aged 9–14y were the primary vaccination beneficiaries, while parents, caregivers, teachers, religious leaders, and community stakeholders were engaged to strengthen vaccine acceptance. Implementation data were collected through attendance records, field notes, dialogue summaries, and reflections. Descriptive statistics and qualitative content analysis were used. The initiative reached over 500 adolescent girls through school awareness activities and engaged 45 community stakeholders across six sites. Two community dialogue sessions were conducted, 1,000 educational materials distributed, and 100 eligible girls received HPV vaccination. Community discussions identified concerns about fertility, vaccine safety, and gender targeting, while trust in health workers, school involvement, participatory dialogue, and community leader support facilitated engagement. Youth-led, community-centered engagement highlighted lessons for improving HPV vaccination through addressing misinformation, building trust, and strengthening health system readiness.

Background

Cervical cancer remains one of the leading causes of cancer-related morbidity and mortality among women in sub-Saharan Africa. Malawi currently has the second-highest cervical cancer incidence globally, estimated at 70.9 cases per 100,000 women.¹ The disease continues to place a substantial burden on women, families, and the health system, particularly in low-resource settings where access to preventive services and early screening remains limited.² Persistent infection with oncogenic strains of Human Papillomavirus (HPV) remains the primary cause of cervical cancer, making HPV vaccination one of the most effective preventive interventions available.^3,4 When administered before exposure to the virus, the vaccine has the potential to significantly reduce future cervical cancer incidence and mortality, contributing to long-term improvements in women’s health outcomes.^4,5

Despite the availability of HPV vaccines through Malawi’s Expanded Programme on Immunization (EPI), vaccine uptake remains suboptimal.⁶ National programmatic data indicates that only approximately 38% of eligible girls have received at least one dose of the HPV vaccine, while Lilongwe District reported coverage as low as 20% in 2025. Although cervical cancer remains the most common HPV related cancer and a major cause of mobility and mortality among women globally, HPV infection is also associated with other cancers affecting both women and men including oropharyngeal cancers. Although epidemiological data on HPV related cancers other than cervical cancer are limited and not systematically reported, available estimates indicate that cervical cancer represents a high cancer burden in Malawi. The estimated crude incidence of cervical cancer is 42.7 per 100,000 population, compared with 1.00, 0.88, 0.81, 0.86 and 0.13 per 100,000 among females for vulvar, vaginal, anal, oral cavity and laryngeal HPV related cancers, respectively.⁷ While HPV represents a cancer burden in both sexes, cervical cancer remains the predominant HPV-related cancer burden. Therefore, this burden provides a strong public health rationale for prioritizing adolescent girls in Malawi’s HPV vaccination program, with vaccination before HPV exposure offering an opportunity to prevent high-risk HPV infection and reduce the future burden of cervical cancer. Low vaccine uptake in Malawi reflects not only service delivery challenges but also broader social and community-level barriers that affect health-seeking behavior.^8,9 Previous studies conducted in Malawi have identified misinformation, cultural beliefs, inadequate awareness, fear of side effects, and parental hesitancy as key barriers to HPV vaccine uptake^9–11

Evidence suggests that strengthening community engagement, social mobilization and culturally appropriate awareness strategies may significantly improve HPV vaccine acceptance and uptake.^9–12 Community-centered implementation approaches that involve parents, teachers, adolescents, religious leaders, and local health workers may help address misinformation while strengthening trust in vaccination programs.^13,14 Schools, in particular, provide an important platform for reaching eligible adolescent girls and influencing caregivers through existing and trusted community structures.^5,15,16 However, despite increasing recognition of the importance of community engagement, there remains limited documentation of youth-led and community-centered HPV vaccination initiatives implemented within low-resource urban communities in Malawi.

This project was therefore developed in response to the urgent need for practical, community-driven strategies to improve HPV vaccine awareness and acceptance.¹⁷ The initiative aligns with the World Health Organization (WHO) Global Strategy to Eliminate Cervical Cancer, particularly the target of vaccinating 90% of girls against HPV before the age of 15 y by 2030.¹⁷ The project also aligns with Global Health Corps (GHC) Malawi priorities in Sexual and Reproductive Health and Rights (SRHR) and Universal Health Coverage (UHC), which emphasize equitable access to preventive health services and meaningful community participation in health promotion.¹⁸

The intervention further positioned young people as active contributors to public health action and systems change. Guided by principles of Human-Centered Design and Systems Thinking, the initiative emphasized participatory dialogue, community ownership, creative engagement, and peer-centered messaging to create a more responsive and trusted awareness campaign.^19,20 Through this approach, the project sought to empower adolescents, caregivers, and communities with sustainable health knowledge and opportunities for meaningful participation in health decision-making.

This paper describes the implementation of a youth-led HPV vaccine awareness and community engagement initiative conducted at Kawale Primary School in Lilongwe, Malawi, by the Malawi 2025–2026 Global Health Corps Africa Leadership Accelerator (GHC-ALA) fellowship cohort. Rather than evaluating the interventions effectiveness, this paper documents the implementation process, describes community engagement activities, summarizes implementation outputs, explores community perceptions of HPV vaccination identified during dialogue sessions and highlights lessons learned that may inform future implementation of HPV vaccination awareness initiative.

Materials and methods

Design

This study was designed as a descriptive implementation case study to document the planning, implementation, outputs and lessons learned from the Protect Her Future, a school and community engagement program for HPV awareness implemented in Lilongwe District, Malawi. The study was guided by the principle of implementation science and focused on describing how the initiative was implemented, the content in which it was delivered, stakeholder experience, implementation challenges and practical lessons for future HPV vaccination programs.

Unlike interventions effectiveness studies, this implementation case study did not include baseline assessments, comparison groups or follow measurements. Instead it provided a descriptive account of the implementation process and documents implementation outputs and stakeholder experience generated during program delivery.

Setting

The initiative was implemented over two days at Kawale primary school and surrounding communities in Lilongwe District, Malawi. The first day targeted caregivers, faith leaders, school leaders, and parents, while the second day focused primarily on school-based learner engagement activities and on-site vaccination activities supported by local health personnel. Kawale is a densely populated urban and peri urban area served by public health facilities under the Lilongwe District Health office. The community experience challenges commonly associated with HPV vaccine including limited awareness of cervical cancer, misconceptions and low vaccine uptake.

Kawale primary school was purposively selected in collaboration with the Lilongwe District Health Office because it serves a large population of girls within the nationally recommended HPV vaccination age group and provides an appropriate platform for integrating school based health promotion with community engagement activities. The presence of a nearby health facility and accessibility of local vaccination services further supported the selection of the implementation site.

Target population

The primary beneficiaries were girls aged 9–14 y for HPV vaccination. However, because HPV vaccination decisions and community acceptance are strongly influenced by caregivers, trusted community members, the engagement activities also targeted parents and caregivers, teachers, school leaders, religious leaders, community stakeholders and frontline health workers.

Description of the protect her future initiative

The Protect Her Future initiative was designed and implemented by the GHC Africa Leadership Accelerator Malawi (2025–2026), a cohort of young public health professionals in collaboration with the Lilongwe District Health Office, Kawale primary school, community leaders and local health workers. The initiative sought to strengthen awareness of HPV vaccination through coordinated school and community engagement activities while facilitating access to routine HPV vaccination services provided by the District Health Office. Learners participated as recipients of the awareness and were not involved in the design of the interventions.

Implementation was informed by participatory community engagement principles, recognizing that vaccine confidence is influenced by interactions among individuals, families, schools, communities and health systems. Accordingly, the initiative adopted a multi component approach that engaged learners and key community stakeholders simultaneously.

The intervention comprised complementary implementation components:

Stakeholder engagement and community entry

Stakeholder engagement formed a critical component of the project implementation process. Before the awareness activities, the project team conducted consultations and planning meetings with key district and community stakeholders to introduce the project objectives, strengthen partnerships, and ensure community ownership of the intervention.

Engagement activities included meetings with representatives from the Ministry of Health through the Lilongwe District Health Office, local health workers, school representatives, community leaders, Parent Teacher Association (PTA) members, religious leaders, and traditional leaders. These consultations aimed to identify local concerns related to HPV vaccination, understand barriers affecting vaccine uptake, and obtain recommendations on culturally appropriate communication approaches for engaging community members.

The Lilongwe District Health Office, particularly the EPI Coordinator and Health Promotion Officer, provided strategic guidance regarding the implementation approach, stakeholder engagement processes, and site selection. District health officials also supported the intervention through the provision of technical expertise, vaccinators, health promotion personnel, and mobile outreach support during implementation activities.

Engagement with the Ministry of Education and school leadership facilitated access to Kawale Primary School and strengthened coordination with teachers and School Health and Nutrition (SHN) personnel. Community entry was further supported through collaboration with traditional and religious leaders who played an important role in building trust, mobilizing participation, and promoting positive attitudes toward HPV vaccination within the community.

Additional partnerships were established with organizations, including Malawi-Liverpool-Wellcome Programme (MLW) and Clinical Research Education and Management Services (CREAMS, which provided material and logistical support for the implementation activities. MLW contributed T-shirts, notebooks, bags, and reusable water bottles to support learner participation and morale during the campaign activities.

HPV awareness and community engagement activities

The project implemented a multi-component awareness and engagement strategy designed to improve knowledge about HPV, cervical cancer prevention, and HPV vaccination while addressing myths and misconceptions contributing to vaccine hesitancy.

Community awareness sessions

Interactive awareness sessions were conducted by fellows and local health workers using simplified and culturally appropriate communication methods. Sessions focused on explaining HPV infection, its relationship with cervical cancer, the importance of early vaccination, vaccine safety, eligibility criteria, and available vaccination services. Facilitators used local examples and participatory discussion methods to improve understanding and encourage engagement among participants.

To extend the reach of the awareness campaign, a mobile van was utilized to deliver cervical cancer prevention messages and mobilize community participation within the surrounding areas. The outreach strategy enabled the dissemination of health messages beyond the immediate school setting and increased visibility of the campaign within the community.

Educational materials and health messaging

Simplified educational materials, including flyers and visual information materials, were distributed during the intervention. The materials provided information on HPV vaccination benefits, vaccine safety, eligibility, and access points for vaccination services. Small learner incentives such as notebooks and pens were also distributed during awareness sessions to encourage participation and engagement.

Myth-busting and interactive discussions

Interactive myth-busting discussions were integrated throughout the awareness sessions to address common misconceptions surrounding HPV vaccination. Participants were encouraged to openly share concerns, fears, and questions regarding the vaccine. Local health workers and facilitators responded to these concerns through clarification and evidence-based health education aimed at improving trust and confidence in HPV vaccination.

Participatory community dialogue activities

Participatory and creative engagement approaches were incorporated into the intervention to improve learner participation and strengthen communication around HPV vaccination.

Role-play and communication activities

Girls participated in role-play activities that simulated conversations with parents and guardians regarding HPV vaccination. These activities were intended to strengthen communication skills, confidence, and learner capacity to discuss vaccination-related issues within their households.

Community dialogue and public engagement

A larger community dialogue session was conducted involving adolescent girls, parents, guardians, teachers, religious leaders, community leaders, and other community members. The session utilized participatory discussion approaches aimed at strengthening community understanding of HPV vaccination and addressing persistent misconceptions.

Activities included interactive myth-busting exercises, open question-and-answer forums with health workers, and public sharing of youth-generated messages and creative materials. Community concerns, perspectives, and recommendations raised during these discussions were documented to inform future HPV vaccination awareness and sensitization strategies.

Facilitation of HPV vaccination services

The project collaborated with local health workers and the Lilongwe District Health Office to facilitate HPV vaccination services for eligible girls aged 9–14 y during the outreach activities. Vaccination services were provided on-site with support from trained vaccinators and health personnel. Eligible learners whose parents or guardians provided consent were vaccinated during the intervention, while additional participants were informed about nearby facilities where HPV vaccination services could be accessed for follow-up vaccination.

Data sources, documentation and reflection

This implementation study utilized routinely collected implementation documentation rather than data collected through a formal research protocol. Information presented in this paper was compiled from multiple sources generated during program implementation including: attendance registers for stakeholders meetings and awareness sessions; routine vaccination records maintained by the District Health Office; facilitator summary notes from community dialogue sessions; implementation activity reports; observation documented by members of the implementation team; and reflective debrief discussions conducted following completion of the initiative. Documentation focused on capturing community responses, implementation experiences, emerging challenges, stakeholder perspectives, and lessons learned throughout. Fellows reflected on how community relationships, stakeholder coordination, resource limitations, and trust influenced implementation processes and project outcomes.

Evaluation and data analysis

The evaluation focused on documenting implementation processes and outputs rather than assessing intervention effectiveness. Quantitative implementation data including the number of participants reached, stakeholders engagement activities conducted, educational materials distributed and the HPV vaccine doses administered during the outreach, were summarized using descriptive statistics. Qualitative information obtained from facilitator summary notes, implementation reflections and community dialogue discussions was analyzed using thematic content analysis approach. Quotes were translated from Chichewa to English. Members of the implementation team independently reviewed the documented notes particularly to identifying recurring community concerns regarding HPV vaccination, implementation challenges, and lessons that could inform future programs.

Ethical considerations

This paper describes the implementation of a routine public health outreach activity conducted as part of the Malawi Ministry of Health Expanded Programme on Immunization (EPI). The activities reported were implemented as routine program delivery and quality improvement rather than as research involving human participants. Consequently, no formal application for National Health Sciences Research Committee (NHSRC) ethical review was submitted.

Administrative permission to implement the outreach activities was obtained from the Lilongwe District Health Office and the District Expanded Programme on Immunization (EPI). Activities were conducted in collaboration with participating schools, community leaders, and Ministry of Health workers.

HPV vaccination was delivered by trained Ministry of Health workers following national EPI procedures. Parents or guardians of eligible girls provided verbal informed consent through the routine EPI vaccination process.

For the community dialogue sessions, facilitators explained the purpose of the discussions, informed participants that participation was entirely voluntary, and clarified that information shared would be used only to improve program implementation and for reporting aggregated implementation findings. Participants provided verbal informed consent before taking part. Verbal rather than written consent was considered appropriate because the dialogue sessions formed part of routine community engagement activities, no sensitive personal information was collected, participation posed no more than minimal risk, and no personal identifiers were recorded. All findings are reported in aggregate to protect participant confidentiality.

Results

Demographic details of community dialogue participants

A total of approximately 1616 learners were enrolled at Kawale Primary School, including approximately 949 girls and 667 boys. The initiative primarily benefited girls aged 9–14 y who were eligible for HPV vaccination under Malawi’s national EPI program. During implementation, ~500+ girls participated in school-based HPV awareness activities, while 100 eligible girls received HPV vaccination through routine services provided by the Lilongwe District Health Office. Refer to Table 1.

Table 1.

Characteristics of the intervention setting and primary beneficiaries.

Characteristic	Description
Study setting	Kawale Primary School, Lilongwe District
School enrolment	Approximately 1616 learners
Girls enrolled	Approximately 949 learners
Boys enrolled	Approximately 667 learners
Primary target beneficiaries	Girls aged 9–14 y eligible for HPV vaccination
Girls reached through HPV awareness activities	~500+
Girls receiving HPV vaccination during outreach	100
Educational materials distributed (HPV information Leaflets)	1000
Dialogue sessions conducted	2
Community outreach sites	6

Demographic details of the stakeholders

A total of 45 stakeholders participated in the initiative, representing school leadership, teachers, parents and caregivers, community leaders, faith leaders, and health workers. Their participation was central to supporting community engagement, addressing misconceptions, dialogue sessions and facilitating implementation of the HPV vaccine awareness activities. Refer to Table 2.

Table 2.

Participants engaged during stakeholder’s meetings and community dialogue sessions.

Stakeholder group	Number (n)	Role in the initiative
Parent–Teacher Association members	3	Participated in dialogue sessions; supported school–community coordination
Mother Group members	6	Participated in dialogue sessions; supported caregiver mobilisation
School Management Committee members	2	Participated in dialogue sessions; supported school coordination
Parents and caregivers	7	Participated in dialogue sessions; shared perspectives and informed vaccination decisions
Teachers and school leadership	4	Participated in dialogue sessions; facilitated learner mobilisation and school activities
Community leaders	5	Participated in dialogue sessions; supported community mobilisation
Health workers	14	Participated in dialogue sessions; provided health education and administered HPV vaccines

Intervention reach and implementation outputs

The Protect Her Future initiative was implemented over a two-day period using school- and community-based engagement activities integrated with routine HPV vaccination services provided by the Lilongwe District Health Office. The implementation reached multiple stakeholder groups, including adolescent girls, parents and caregivers, teachers, school leaders, community leaders, religious leaders, Parent–Teacher Association representatives, School Management Committee members, Mother Group members, and frontline health workers.

School-based awareness activities reached ~500+ girls enrolled at Kawale Primary School, who participated in interactive educational sessions on HPV infection, cervical cancer prevention, and HPV vaccination. Community engagement activities included two dialogue sessions involving 45 stakeholders representing education, health, and community leadership structures. Educational materials, including HPV information leaflets, were distributed during the awareness sessions, and community outreach activities were conducted at six locations within the surrounding community.

Routine HPV vaccination services were provided on-site by trained health workers from the Lilongwe District Health Office. During the outreach, 100 eligible girls received HPV vaccination in accordance with Malawi’s Expanded Programme on Immunization (EPI) guidelines. Although community interest in vaccination exceeded the available vaccine supply, vaccine availability limited the number of eligible girls who could be vaccinated during the outreach. Consequently, the number of vaccine doses administered should be interpreted as an implementation output of the outreach activity rather than a measure of vaccine acceptance or program effectiveness.

Implementation facilitators identified during community engagement

Implementation reflections and community dialogue sessions identified several factors that appeared to facilitate community engagement and support implementation of the HPV awareness initiative. These observations were consistently documented by facilitators and reflected participants’ experiences during the engagement activities.

One important facilitator was the involvement of trusted health workers throughout the awareness sessions and community dialogs. Participants frequently directed questions regarding vaccine safety, eligibility, and potential side effects to nurses and District Health Office staff, who provided clarification using evidence-based health information. Their presence contributed to open discussions and provided an opportunity for participants to seek clarification on issues that had previously contributed to uncertainty.

The use of Kawale Primary School as the implementation platform also facilitated program delivery. The school provided an accessible and familiar environment where learners, teachers, caregivers, and health workers could participate in awareness activities. Participants indicated that conducting the sessions within the school setting encouraged attendance and created opportunities for communication between learners and their caregivers regarding HPV vaccination.

Interactive dialogue approaches further supported implementation by creating opportunities for participants to openly discuss concerns and ask questions. Rather than relying solely on didactic health education, facilitators used participatory discussions, question-and-answer sessions, and myth-busting activities that encouraged community members to share their perspectives and engage directly with health workers.

Community leaders, religious leaders, and school representatives also contributed to implementation by mobilizing community members, encouraging participation in dialogue sessions, and supporting communication between the implementation team and the wider community. Their involvement helped strengthen coordination of community engagement activities and promoted local ownership of the initiative.

Finally, participatory learner activities, including role-play exercises and creative health messaging, encouraged active engagement among adolescent girls during the school-based sessions. Facilitators observed that these approaches enabled learners to discuss HPV vaccination more confidently and actively participate in awareness activities alongside their peers.

Overall, these implementation experiences suggest that collaboration between schools, community leadership structures, and frontline health workers, together with participatory communication approaches, supported delivery of the awareness initiative and provided practical lessons for planning similar community engagement activities in the future.

Community perceptions and emerging themes

Community dialogue sessions provided an opportunity to document questions, concerns, and perspectives related to HPV vaccination among parents, caregivers, community leaders, teachers, and other stakeholders. Thematic content analysis of facilitator notes and implementation reflections identified four recurring themes: concerns regarding vaccine safety and fertility, questions regarding HPV vaccination of boys, the importance of trusted sources of information, and the value of interactive community dialogue.

Theme 1: concerns regarding vaccine safety and fertility

A recurring concern raised during community discussions related to whether HPV vaccination could affect girls’ future fertility. Some participants reported hearing community narratives suggesting that the vaccine might interfere with reproductive health. These concerns were discussed openly during dialogue sessions, allowing health workers to provide clarification regarding vaccine safety and the purpose of HPV vaccination as a cervical cancer prevention intervention.

One parent expressed:

We heard that the vaccine may make girls infertile in the future. We wanted health workers to explain whether this was true. (Parent, community dialogue session)

Another participant asked:

How can we be sure that this vaccine will not affect our children when they grow up and want to have families? (Caregiver, community dialogue session)

These discussions highlighted that concerns were often linked to uncertainty and misinformation rather than outright refusal of vaccination. Participants valued opportunities to receive information directly from trusted health workers and community representatives.

Theme 2: questions regarding HPV vaccination of boys

Participants also raised questions regarding why Malawi’s HPV vaccination program currently prioritizes adolescent girls while HPV infection affects both females and males. Some community members questioned whether focusing vaccination efforts only on girls adequately addressed HPV prevention.

A community leader asked:

If HPV affects everyone, why are boys not receiving the vaccine as well? (Community leader, community dialogue session)

Another participant noted:

We understand protecting girls from cervical cancer, but we also want to know how boys are protected from HPV. (Parent, community dialogue session)

These discussions provided an opportunity for facilitators and health workers to explain Malawi’s current strategy of prioritizing adolescent girls due to the high burden of cervical cancer while acknowledging the broader importance of HPV prevention across genders.

Theme 3: importance of trusted information sources

Participants emphasized the importance of receiving HPV vaccine information from trusted sources, particularly health workers, teachers, and community leaders. Many questions raised during discussions reflected a desire for accurate information rather than resistance to vaccination.

One caregiver shared:

After the nurse explained how the vaccine works, I understood why my daughter should receive it. I also understood that us as adult, we need to go for screening, and ensure that our young girls are vaccinated (Caregiver, community dialogue session)

Another participant stated:

When information comes from people we trust, it is easier to understand and accept. (Parent, community dialogue session)

The discussions suggested that trusted messengers played an important role in creating spaces where community members felt comfortable discussing sensitive questions related to HPV vaccination.

Theme 4: preference for interactive dialogue approaches

Participants expressed appreciation for the opportunity to ask questions and engage directly with health workers and facilitators. The dialogue format allowed community members to raise concerns that may not have been addressed through traditional one-way health education approaches.

One parent commented:

Todays discussion allowed us to ask questions we had never been able to ask before. (Parent, community dialogue session)

Another participant reflected:

When people understand why something is important, they are more willing to support it. (Community member, community dialogue session)

These reflections reinforced the importance of participatory communication approaches that allow communities to share concerns, seek clarification, and contribute to health discussions.

Reflections from participatory dialogue activities

Participatory activities included learner role-play exercises, creative messaging activities, and community dialogue sessions involving parents, caregivers, teachers, community leaders, and health workers.

During learner sessions, girls participated in role-play activities focused on discussing HPV vaccination with parents and guardians. Learners also developed drawings and slogans under the theme “Protect Her Future,” expressing messages related to HPV prevention and vaccination.

Community dialogue sessions provided opportunities for participants to ask questions, discuss concerns, and interact directly with health workers. Facilitator observations documented active participation during question-and-answer sessions and myth-busting discussions.

Participants particularly engaged with activities that allowed open discussion rather than one-way health education. Parents and caregivers used these sessions to raise questions regarding vaccine safety, eligibility, and the rationale for vaccinating girls.

Implementation challenges

Several implementation challenges were encountered during the execution of the HPV vaccine awareness and vaccination initiative. These challenges highlight the complexity of delivering community-based health interventions in resource-constrained and dynamic field settings.

One of the primary challenges was scheduling and coordination delays resulting from competing commitments among District Health Office (DHO) staff and supporting stakeholders. These shifts required repeated adjustments to the implementation timeline and affected pre-planned engagement activities.

A second major challenge was the unexpected increase in demand for HPV vaccination following the awareness sessions. While demand for vaccination appeared higher than the available vaccine supply, the available doses were insufficient to vaccinate all eligible girls who sought vaccination during the outreach period.

The project also experienced community-level disruptions, including a bereavement within the targeted community on the day of stakeholder engagement. This affected the attendance of key participants, particularly members of the Parent Teacher Association (PTA) and other community representatives.

In addition, resource constraints posed limitations in scaling up outreach activities to reach larger populations despite high community interest. The project had to continuously adapt its budget and implementation strategies to remain within available financial and logistical resources.

Finally, delays in feedback and administrative approvals from some institutional stakeholders occasionally slowed planning processes and coordination with implementing partners.

Despite these challenges, adaptive planning, strong stakeholder collaboration, and continuous communication enabled successful completion of the intervention.

Discussion

This youth-led, community-centered HPV vaccine awareness and vaccination initiative provides practical insights into the feasibility of integrating participatory engagement strategies into routine immunization efforts in low-resource settings. The implementation experience demonstrated that combining community dialogue, trust-building approaches, and interactive learning activities can support HPV vaccine awareness and facilitate linkage between communities and available vaccination services. However, given the descriptive nature of this study, the findings should be interpreted as implementation lessons rather than evidence of intervention effectiveness.

The findings align with the World Health Organization Global Strategy to Eliminate Cervical Cancer, which recommends achieving 90% HPV vaccination coverage among girls by age 15 y alongside strengthened screening and treatment services.¹⁷ In this initiative, school-based engagement activities were combined with community dialogue and vaccination services provided through the District Health Office. This approach illustrated the importance of linking demand-generation activities with service availability.²¹ However, the observed gap between increased community interest and limited vaccine availability highlights an important implementation challenge: awareness efforts must be accompanied by adequate vaccine supply, logistics planning, and service delivery capacity to ensure that demand can be converted into timely access.

From an implementation science perspective, several contextual factors appeared to influence implementation. Although this study did not formally apply the Consolidated Framework for Implementation Research (CFIR), the findings can be interpreted through similar implementation domains, including external context, organizational readiness, and characteristics of individuals involved in implementation.²² Community beliefs, misinformation, and caregiver concerns represented important external influences, while collaboration between schools, health workers, and community structures supported implementation readiness. Furthermore, trusted individuals, particularly health workers and community leaders, played an important role in facilitating communication and creating opportunities for communities to discuss concerns related to HPV vaccination.

A key lesson from the project was the value of participatory communication approaches. Role-play activities, creative learner messaging, myth-busting discussions, and open community dialogs created opportunities for participants to ask questions and discuss concerns that may not have emerged through traditional one-way health education approaches. These findings support existing evidence that vaccine communication strategies are more likely to address hesitancy when they are based on dialogue, trust-building, and community participation rather than simply information dissemination.^20,23

The findings also highlight the importance of schools as platforms for adolescent health interventions. Schools provided an accessible and trusted environment for reaching eligible girls while also enabling engagement with teachers, caregivers, and community stakeholders. This supports evidence that school-based HPV vaccination approaches can improve access among adolescents, particularly when complemented by community communication strategies that address caregiver concerns and strengthen acceptance of vaccination services.

Beyond communication activities, this initiative highlights the importance of considering HPV vaccination as a broader health system intervention. Vaccine confidence and uptake are influenced by interconnected factors, including community trust, misinformation, social norms, accessibility of services, and health system preparedness. Therefore, improving HPV vaccination coverage requires coordinated approaches involving communities, schools, health systems, and local leadership structures rather than isolated awareness campaigns.

The experience also demonstrates the potential contribution of young public health professionals in supporting community engagement and health promotion activities. Through participatory approaches and collaboration with existing community structures, the GHC fellows supported communication between health services and communities. Future initiatives could further strengthen youth engagement by involving adolescents and young people not only as participants but also as co-designers and advocates of HPV vaccination strategies.

Limitations

This study has several limitations that should be considered when interpreting the findings. First, this was a descriptive implementation case study designed to document implementation processes, outputs, stakeholder experiences, and lessons learned rather than evaluate intervention effectiveness. The study did not include baseline assessments, a comparison group, or pre- and post-intervention measurements; therefore, it cannot determine whether the initiative caused changes in HPV vaccine knowledge, acceptance, or uptake.

Second, the initiative was implemented over a short two-day period at a single urban primary school and surrounding communities in Lilongwe District. While this provided an opportunity to document implementation experiences within a real-world setting, the findings may not be transferable to rural communities, other districts, or populations with different social and health system contexts. Additionally, the implementation site was purposively selected in collaboration with the District Health Office based on accessibility, population characteristics, and suitability for school-based HPV vaccination activities, which may limit generalizability.

Third, the study relied on routinely collected implementation documentation, including attendance registers, vaccination records, facilitator notes, activity reports, and reflective debriefs rather than data collected through a formal research protocol. Although thematic content analysis was used to identify recurring themes from community dialogue sessions and implementation reflections, the qualitative findings should be interpreted as implementation insights rather than comprehensive assessments of community beliefs or vaccine hesitancy. The absence of audio recordings, formal qualitative interviews, and independent qualitative coders may have limited the depth and interpretive reliability of the qualitative findings.

Fourth, community perceptions and vaccine acceptance were not measured using validated instruments. Although participants raised concerns and provided feedback during dialogue sessions, these discussions cannot be interpreted as a quantitative measure of vaccine confidence or acceptance. Similarly, the 100 HPV vaccine doses administered during the outreach represent an implementation output and should not be interpreted as evidence of increased vaccine uptake attributable to the intervention. Vaccine availability was limited during the outreach period, and some eligible girls who were interested in vaccination could not receive the vaccine. Therefore, the number vaccinated reflects both community demand and available service capacity.

Fifth, although this initiative is described as youth-led, the intervention was led by young public health professionals from the Global Health Corps Africa Leadership Accelerator, while adolescent girls participated primarily as beneficiaries of the awareness activities. Future initiatives could strengthen youth participation by involving adolescents more actively in intervention design, message development, and implementation planning.

Finally, the intervention focused on girls aged 9–14 y in alignment with Malawi’s current HPV vaccination strategy. The findings therefore do not assess perspectives or vaccination approaches involving boys, despite HPV being associated with health outcomes affecting all genders. However, some community participants questioned why boys were not also targeted by the campaign, highlighting the broader relevance of HPV prevention. As males play important role to acquire and transmit high-risk HPV types and act as reservoirs of infection, increasing HPV awareness and prevention among boys and men is important to support comprehensive prevention efforts²⁴While prioritizing adolescent girls remains appropriate given the high burden of cervical cancer. Future research should explore broader gender-inclusive HPV prevention strategies and assess how community engagement approaches can support evolving national vaccination priorities.

Implications for practice and policy

This study has several implications for HPV vaccination programs in Malawi and similar settings. First, strengthening community engagement through youth-led and participatory models can enhance vaccine acceptance and trust. Second, implementation strategies must be aligned with health system capacity to ensure vaccine availability during outreach activities. Third, engaging schools, religious leaders, and community structures should be considered a core component of HPV vaccination delivery strategies rather than an optional add-on.

Finally, integrating implementation science approaches into routine public health programming can improve understanding of context-specific barriers and facilitate more adaptive and responsive interventions.

Conclusion

This descriptive implementation case study provides practical lessons on the importance of socially embedded, systems-informed, and community-centered approaches for HPV vaccine awareness activities in low-resource settings. The experience highlights that addressing misinformation, strengthening trust, and engaging communities as partners are important considerations when designing and implementing HPV vaccination communication strategies.

The initiative illustrated how youth professional-led coordination, school-based outreach, community dialogue, and interactive learning approaches can support engagement between communities and health systems and create opportunities to discuss concerns related to HPV vaccination. However, the findings should not be interpreted as evidence of intervention effectiveness or increased vaccine acceptance, as this study did not include baseline assessments, comparison groups, or follow-up evaluation.

The implementation experience further emphasizes that demand-generation activities must be accompanied by health system readiness, including reliable vaccine availability, coordinated service delivery, and effective referral mechanisms, to ensure that communities who are informed and willing to vaccinate can access services.

Future research should evaluate the effectiveness, sustainability, and scalability of community-centered HPV vaccination strategies using robust evaluation designs. Such evidence will be important for informing Malawi’s ongoing efforts toward achieving the World Health Organization cervical cancer elimination targets.

Funding Statement

No external research grant funding was received specifically for this manuscript. The community engagement initiative was implemented as part of the Global Health Corps (GHC) Malawi 2025–2026 Cohort Coalition Initiative. Implementation was supported through cohort program resources and in-kind contributions from collaborating institutions, including the Malawi Liverpool Wellcome Trust Clinical Research Programme (MLW) and Clinical Research Education and Management Services (CREAMS), which provided materials and logistical support for community engagement activities. The funders had no role in the study design, analysis, interpretation of findings, preparation of the manuscript, or the decision to submit the manuscript for publication.

Disclosure statement

No potential conflict of interest was reported by the author(s).