Author: Dr Espira Eubert, Dr Elizabeth Kemigishia, Dr Abdhalah Ziraba and The HPV Impact assessment team
Introduction
Cervical cancer is a significant public health challenge in sub-Saharan Africa, and it is the leading cause of cancer-related deaths among women. Globally it is the fourth most common cancer in women with around 660,000 new cases and around 350,000 deaths in 2022 (WHO: Cervical cancer fact sheet.). Each year, 600–700 new cases lead to 500–600 deaths, fueled by limited screening and treatment. Global HPV prevalence (26–32%) far exceeds global averages, while women with HIV face a five times higher risk in a country where HIV affects 1.1% of adults (WHO HPV Fact Sheet, CDC Global HIV Statistics). Liberia faces one of the highest cervical cancer burdens globally, with an age-standardized incidence rate (ASIR) of 31.5 per 100,000 women and a mortality rate (ASMR) of 23.9 per 100,000 (Globocan 2022). The Human Papillomavirus (HPV) vaccine, which protects against the strains of HPV responsible for most cervical cancer cases, offers a powerful tool for prevention. However, despite its proven efficacy and safety, the uptake of HPV vaccination program in Liberia has been slow, hindered by cultural, religious, and social sensitivities (World Bank Blog). Without expanded HPV vaccination and screening, preventable deaths will remain high. This blog calls for open dialogue and community engagement to address barriers and ensure the successful coverage and uptake of HPV vaccination programs in Liberia.
Liberia, a post-conflict nation, faces numerous challenges in its healthcare system, including limited infrastructure, inadequate funding, and a shortage of trained healthcare workers. These challenges are compounded by deeply rooted cultural and religious beliefs that influence health-seeking behaviours and attitudes toward medical interventions. HPV vaccination, which targets adolescents, often sparks controversy due to misconceptions about its purpose and safety.
In 2016, Liberia introduced the HPV vaccine with support from Gavi, the Vaccine Alliance. In 2019, Liberia integrated the HPV vaccine into its routine immunization program, yet coverage remains critically low, with only 15-20% of eligible girls (9-14 years) completing the two-dose series; well below the WHO’s 90% target ( WHO’s 90% target). The 2022–2023 school-based campaign reached just 30% for the first dose, with even fewer second doses administered, particularly in rural areas where healthcare access is limited and cultural resistance persists (UNICEF, MoH Liberia). Studies show that successful HPV vaccination programs in settings like Liberia require strong community engagement, including trusted religious and male leaders, to counter skepticism about vaccinating adolescents against an STI-linked disease ( UNICEF Liberia, 2022). In Liberia, where men and religious leaders hold significant influence over household and community decisions, their participation in sensitization efforts is critical to overcoming vaccine hesitancy ( UNICEF Liberia Report, 2022).
Data to assess the performance of Liberia’s HPV vaccination program are sparse, limiting understanding of the risks, inequities, and drivers of low coverage. However, available evidence shows that access to vaccination services among adolescents is low, while early sexual debut and female genital cutting; both significant risk factors for HPV infection, remain common. Fears of infertility, limited awareness, mistrust from the Ebola crisis, and gender dynamics further challenge uptake, with only 19% of girls vaccinated before sexual debut despite early initiation (median age 16.1 for girls vs. 18.5 for boys) and wide disparities by education, wealth, and location (DHS 2019–20; UNICEF Liberia 2021).
The Problem
In Liberia, patriarchal norms and religious conservatism create significant barriers to adolescent HPV vaccination, despite women’s central role in childhood immunization. A majority (72%) of Liberian women report that husbands or partners dominate healthcare decisions for adolescents (DHS 2019-20, p. 289), and male-led parental refusal was a top reason for missed HPV doses during Liberia’s 2021 rollout (MoH Liberia & Gavi 2022). Religious leaders further amplify hesitancy—58% of rural pastors oppose the vaccine over unfounded “promiscuity” concerns (UNICEF Liberia 2023), with protests halting school campaigns in Grand Bassa County (FrontPage Africa 2022). While mothers drive 65% measles coverage (WHO 2023), 41% of adolescent girls cannot access care without male caregiver permission (DHS 2019-20, p. 314), and HPV uptake plummets to 19% in male-headed households versus 34% in female-headed ones (MoH Liberia 2023 leak). . Historically, men have been less involved in reproductive health discussions, but their engagement is crucial for the success of HPV vaccination programs. Similarly, religious leaders, who are often seen as moral authorities, can play a pivotal role in dispelling myths and encouraging vaccine acceptance. However, this requires them to “walk the talk” by educating themselves about the vaccine and advocating for its benefits. This was witnessed during Liberia’s COVID-19 vaccination campaign, where religious and community leaders “walked the talk” by publicly receiving vaccines, educating their followers, and dispelling myths leading to increased trust and uptake, particularly in hesitant rural areas. Their advocacy, supported by the government and international partners like the Centre for Disease Control (CDC), demonstrated the power of local leadership in overcoming vaccine resistance and promoting public health.
Call to action
Liberia has made strides in improving its healthcare infrastructure, but the success of HPV vaccination programs depends on more than just logistics. It requires a societal shift in how we approach sensitive health topics. Open dialogue, led by trusted community figures, can help bridge the gap between scientific evidence and public perception. Involving men and religious leaders in sensitization campaigns can create a more inclusive and supportive environment for HPV vaccination (World Bank Trusted Voices session).
The HPV Impact Assessment Study, led by the African Population and Health Research Center (APHRC) and funded by Gavi and the Bill & Melinda Gates Foundation in collaboration with UNICEF, WHO, national EPI programs, Liberia’s Ministry of Health and Ministry of Education, the University of Liberia, and Gavi representatives, aims to improve methods for measuring HPV vaccination coverage and equity in Liberia (2024-2026). The study addresses critical gaps in current data by validating administrative records against household surveys, assessing sociodemographic barriers to uptake, and testing innovative, cost-effective data collection approaches. A technical committee comprising of all the national level collaborators (WHO, UNICEF, GAVI, EPI, MoH, MoED, Academia) has been set-up to be able to provide technical oversight for the implementation of the project. The mixed-methods design incorporates sero-surveys, gender analysis, and community engagement to ensure robust, actionable insights for HPV program scaling. The study will inform policies to accelerate progress toward the WHO’s 90% vaccination target by 2030.
A recent visit to Montserrado County for the HPV Impact inception meeting highlighted the importance of open dialogue on HPV awareness and vaccination. The Ministry of Education (MoED) has taken a proactive approach, engaging religious and traditional leaders to spread awareness about HPV and the vaccination program for adolescent girls aged 9–14. Their influential role in the community makes them key advocates for this cause. Collaboration between the MoED and the Ministry of Health (MoH) has ensured that gender equity and social inclusion remain central to Liberia’s HPV vaccination efforts. Schools, health facilities, and community outreach have all been leveraged to expand access, while both ministries have recognized the importance of involving men and boys to boost uptake. Building on this, greater emphasis on open dialogue about sensitive health topics — led by trusted community and religious leaders can bridge gaps between scientific evidence and public perception. Learning from existing partnerships, future campaigns should expand engagement with fathers, male caregivers, and faith leaders to create a more inclusive, supportive environment for HPV vaccination (World Bank Trusted Voices). Education officers, teachers, and school administrators have undergone training on HPV, equipping them with the knowledge to educate parents through Parent-Teacher Associations. As a result, more schools have adopted school-based surveys to track vaccination status, ensuring eligible girls receive both doses.
Conclusion
Liberia has made modest strides in healthcare infrastructure, yet the success of HPV vaccination programs hinges not just on logistics but on societal acceptance. Open dialogue, led by trusted community and religious leaders, is critical to bridging the gap between scientific evidence and public perception particularly for a vaccine that touches on culturally sensitive topics. The HPV Impact Assessment Study (2024–2026), led by APHRC in collaboration with UNICEF, WHO, Gavi, Liberia’s EPI, Ministry of Health, Ministry of Education, and the University of Liberia, aims to address these challenges holistically. By improving coverage measurement approaches, the study will generate actionable insights to improve HPV vaccine programming especially for marginalized groups, including out-of-school girls and migrant populations.