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Peer-reviewedCC BYPLOS One

Navigating HPV vaccination challenges in low-resource settings: Practical strategies for estimating the size of out-of-school girls

  • Soim Park1
  • Erica N Rosser1
  • Leanne Zhang1
  • Megan D Wysong1
  • Arman Majidulla1
  • Marina Terada2
  • Pamela J Surkan1
  • Joseph G Rosen3,4,5
  • Rupali J Limaye1,6
6 affiliations
  1. 1Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America.
  2. 2Department of Health, Behavior and Society, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America.
  3. 3Division of General Internal Medicine, Rhode Island Hospital, Rhode Island, United States of America.
  4. 4Department of Medicine, Warren Alpert Medical School, Brown University, Providence, Rhode Island, United States of America.
  5. 5Department of Epidemiology, School of Public Health, Brown University, Providence, Rhode Island, United States of America.
  6. 6Department of Global and Community Health, College of Public Health, George Mason University, Fairfax, Virginia, United States of America.
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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.

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Cite

BibTeXRIS
BibTeX
@article{park2026navigating,
  title = {{Navigating HPV vaccination challenges in low-resource settings: Practical strategies for estimating the size of out-of-school girls}},
  author = {Soim Park and Erica N Rosser and Leanne Zhang and Megan D Wysong and Arman Majidulla and Marina Terada and Pamela J Surkan and Joseph G Rosen and Rupali J Limaye},
  journal = {PLOS One},
  year = {2026},
  month = oct,
  doi = {10.1371/journal.pone.0359273},
  url = {https://doi.org/10.1371/journal.pone.0359273},
  note = {CC BY},
}
RIS
TY  - JOUR
TI  - Navigating HPV vaccination challenges in low-resource settings: Practical strategies for estimating the size of out-of-school girls
AU  - Soim Park
AU  - Erica N Rosser
AU  - Leanne Zhang
AU  - Megan D Wysong
AU  - Arman Majidulla
AU  - Marina Terada
AU  - Pamela J Surkan
AU  - Joseph G Rosen
AU  - Rupali J Limaye
PY  - 2026
DA  - 2026/10/26
JO  - PLOS One
DO  - 10.1371/journal.pone.0359273
UR  - https://doi.org/10.1371/journal.pone.0359273
AB  - 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.
SN  - 1932-6203
ER  -