Enablers and barriers to human papillomavirus vaccination implementation among key stakeholders in Ethiopia: A qualitative study.
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INTRODUCTION: Human papillomavirus (HPV) vaccination is an effective and lifesaving intervention against cervical cancer. However, achieving high, equitable, and sustainable uptake remains a significant challenge in low-resource settings, including Ethiopia. Therefore, this study aimed to explore the enablers and barriers to HPV vaccination implementation in Ethiopia. METHODS: An interpretive descriptive qualitative design was employed in purposively selected settings representing diverse socio-ecological contexts (Afar, Amhara, Addis Ababa, and Dire Dawa). Six focus group discussions were conducted with adolescent girls (n = 14), parents of eligible adolescent girls (n = 14), and community representatives (n = 14). In addition, nineteen key informant interviews (KIIs) were conducted with healthcare providers, Expanded Programme on Immunization (EPI) coordinators, and technical advisors from governmental and non-governmental organizations. Data were analysed using a combined deductive-inductive content analysis guided by the Consolidated Framework for Implementation Research (CFIR 2.0). RESULTS: Multiple interacting factors influenced HPV vaccination implementation in Ethiopia, categorised as enablers and barriers across community, health system, and policy levels. Enablers included the Perceived Vaccine Attributes and Delivery Adaptability, Supportive Policy and Multisectoral Strategic Partnerships, Socio-cultural and Belief-based Drivers, and Health System Readiness and Workforce Motivation. However, several barriers limited implementation, including Suspicions About Targeting 9-14-year-old Girls and Consent-related Administrative Obstacles, Pervasive Misinformation and Cognitive Resistance, Health System Resource Constraints and Coordination Gaps, Donor Dependency Risks and Financial Sustainability Concerns, and Structural Access Constraints and Equity Gaps. CONCLUSIONS: While policy shifts, external strategic partnerships, and frontline worker dedication have accelerated vaccine reach, the long-term sustainability of Ethiopia's HPV vaccination program remains constrained by multi-level barriers. Progress toward the global 2030 cervical cancer elimination targets requires trust-building risk-communication strategies to counter fertility myths, simplified consent procedures, targeted domestic resource mobilization, and context-specific delivery models tailored to underserved pastoralist and urban sub-populations.