Multiple-level stakeholders' perspectives on barriers and facilitators of HPV vaccination delivery in Western and Central Kenya: a qualitative study.

Background: Human papillomavirus (HPV) vaccination is critical for achieving cervical cancer elimination. In Kenya, HPV vaccination coverage progressed slowly since the launch of the national vaccination programme in 2019. We sought to assess the barriers and facilitators of HPV vaccination delivery from the perspective of multilevel stakeholders involved in HPV vaccination in Kenya. Methods: Using a qualitative approach, we interviewed multilevel stakeholders involved in vaccination delivery across multiple levels of the health system in three counties and nationally between February and July 2023. Participants were purposively sampled based on their role in HPV vaccination delivery. We used in-depth interview guides informed by the consolidated framework for implementation research. Interviews were audio-recorded, transcribed and translated into English when necessary. Data were analysed using deductive and inductive thematic approaches. Results: Overall, we interviewed 52 participants, including 22 (42%) community leaders, 19 (37%) healthcare providers and 11 (21%) decision-makers. 34 participants (65%) were females. Participants had been in their role for 9 years on average (IQR: 3-12). Stakeholders reported that strong global, regional and local evidence supported national implementation of HPV vaccination. Adaptations to the intervention, including school-based and community-based vaccination, complemented facility-based approaches and increased coverage. Additionally, the availability of vaccination resources, together with adequate stakeholder engagement, training and motivation, was critical for HPV vaccination delivery. Conversely, training gaps and limited dissemination of evidence to key stakeholders hindered vaccination delivery. Furthermore, logistical constraints, poor coordination and communication among stakeholders and the lack of parental consent challenged school-based delivery. Facility-based vaccination was impeded by inadequate infrastructure and staffing, while community hesitancy hindered vaccination uptake due to inadequate knowledge, insufficient early involvement of key community stakeholders, myths and misinformation. Conclusions: Context-specific approaches that include cross-sectoral collaboration efforts among HPV vaccination stakeholders and targeted sensitisation within communities could improve HPV vaccination delivery and uptake in Kenya and comparable settings.