{ "abstract": "Background: Achieving the 2030 target of 90% human papillomavirus (HPV) vaccination coverage among girls by age 15 requires effectively reaching out-of-school (OOS) girls, particularly in low- and middle-income countries (LMICs) where most vaccine delivery occurs in school settings. This study explored country definitions of OOS girls and strategies for estimating the size of this population. Methods: Between May and September 2024, we conducted semi-structured in-depth interviews with 32 HPV vaccine program stakeholders across six African and Asian LMICs with established HPV vaccination programs: Cambodia, Cameroon, Kenya, Malawi, Mozambique, and Uganda. Using hybrid inductive-deductive thematic analyses, we identified country approaches to defining OOS girls and to enumerating or estimating population size. Results: Administratively, countries commonly defined OOS girls as those not enrolled in schools under the Ministry of Education’s purview, but in practice, definitions varied across contexts. National-level data (e.g., census, school enrollment rates) and household-level approaches (e.g., headcounts) were commonly used to enumerate in-school and OOS girls. However, the distinction between in-school and OOS girls was often blurred during HPV vaccination implementation and evaluation, limiting the operational utility of these methods. To address these challenges, some countries adopted alternative approaches, including proxy-based population estimates using historical or approximate data and the prioritization of areas perceived to have a higher presence of OOS girls. These alternative approaches were perceived as pragmatic compromises between accuracy, feasibility, and resource constraints. Conclusion: Accurate enumeration of OOS girls is important for HPV vaccination but may not be feasible in resource-limited settings. Pragmatic, context-specific estimation methods can offer a feasible way to identify and reach OOS girls more effectively with HPV vaccination services.", "abstract_shown": true, "affiliations": [ "Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America.", "Department of Health, Behavior and Society, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America.", "Division of General Internal Medicine, Rhode Island Hospital, Rhode Island, United States of America.", "Department of Medicine, Warren Alpert Medical School, Brown University, Providence, Rhode Island, United States of America.", "Department of Epidemiology, School of Public Health, Brown University, Providence, Rhode Island, United States of America.", "Department of Global and Community Health, College of Public Health, George Mason University, Fairfax, Virginia, United States of America." ], "article_type": "Research Article", "arxiv": null, "author_total": 9, "authors": [ { "affs": [ 0 ], "name": "Soim Park", "orcid": "0000-0003-3217-1210" }, { "affs": [ 0 ], "name": "Erica N Rosser", "orcid": "0009-0001-3893-869X" }, { "affs": [ 0 ], "name": "Leanne Zhang" }, { "affs": [ 0 ], "name": "Megan D Wysong" }, { "affs": [ 0 ], "name": "Arman Majidulla" }, { "affs": [ 1 ], "name": "Marina Terada" }, { "affs": [ 0 ], "name": "Pamela J Surkan", "orcid": "0000-0002-0334-5931" }, { "affs": [ 2, 3, 4 ], "name": "Joseph G Rosen", "orcid": "0000-0003-4991-4033" }, { "affs": [ 0, 5 ], "name": "Rupali J Limaye" } ], "bibtex": "https://research.draconitic.com/paper/f0fss7bd298d9.bib", "cited_by": 0, "doi": "10.1371/journal.pone.0359273", "fulltext_url": "https://europepmc.org/articles/PMC13704837", "id": "f0fss7bd298d9", "issns": [ "1932-6203" ], "landing_url": "https://doi.org/10.1371/journal.pone.0359273", "language": "eng", "licence": "CC-BY", "licence_label": "CC BY", "licence_source": "article", "licence_url": "https://creativecommons.org/licenses/by/4.0/", "metadata_licence": null, "native_subjects": [ [ "openalex", "2713|Cervical Cancer and HPV Research" ], [ "plos", "/Biology and life sciences/Immunology/Vaccination and immunization" ], [ "plos", "/Biology and life sciences/Microbiology/Medical microbiology/Microbial pathogens/Viral pathogens/Papillomaviruses/Human papillomavirus" ], [ "plos", "/Biology and life sciences/Organisms/Viruses/DNA viruses/Papillomaviruses/Human papillomavirus" ], [ "plos", "/Biology and life sciences/Organisms/Viruses/Viral pathogens/Papillomaviruses/Human papillomavirus" ], [ "plos", "/Earth sciences/Geography/Economic geography/Low and middle income countries" ], [ "plos", "/Medicine and health sciences/Immunology/Vaccination and immunization" ], [ "plos", "/Medicine and health sciences/Medical conditions/Infectious diseases/Infectious disease control/Vaccines" ], [ "plos", "/Medicine and health sciences/Pathology and laboratory medicine/Pathogens/Microbial pathogens/Viral pathogens/Papillomaviruses/Human papillomavirus" ], [ "plos", "/Medicine and health sciences/Public and occupational health/Preventive medicine/Vaccination and immunization" ], [ "plos", "/People and places/Geographical locations/Africa/Cameroon" ], [ "plos", "/People and places/Geographical locations/Africa/Mozambique" ], [ "plos", "/People and places/Geographical locations/Africa/Uganda" ], [ "plos", "/Social sciences/Economics/Economic geography/Low and middle income countries" ], [ "plos", "/Social sciences/Sociology/Education/Schools" ] ], "openalex": "W7223679653", "pdf_url": "https://europepmc.org/articles/PMC13704837?pdf=render", "pmcid": "PMC13704837", "pmid": "42932346", "published": "2026-10-26", "publisher": "Public Library of Science", "ris": "https://research.draconitic.com/paper/f0fss7bd298d9.ris", "sources": [ { "first_seen": "2026-10-30T12:17:17Z", "native_id": "10.1371/journal.pone.0359273", "source": "plos", "url": "https://doi.org/10.1371/journal.pone.0359273" }, { "first_seen": "2026-10-30T12:21:51Z", "native_id": "MED:42932346", "source": "europepmc", "url": "https://europepmc.org/article/MED/42932346" } ], "subjects": [ { "field": "biology", "origin": "plos:immunology", "subfield": "immunology" }, { "field": "biology", "origin": "plos:microbiology", "subfield": "microbiology" }, { "field": "medicine", "origin": "plos:infectious diseases", "subfield": "infectious-disease" } ], "title": "Navigating HPV vaccination challenges in low-resource settings: Practical strategies for estimating the size of out-of-school girls", "title_text": "Navigating HPV vaccination challenges in low-resource settings: Practical strategies for estimating the size of out-of-school girls", "type": "peer-reviewed", "updated_at": "2026-10-30T12:21:51Z", "url": "https://research.draconitic.com/paper/f0fss7bd298d9", "venue": "PLOS One", "versions": [] }