Grace Umutesi

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.

While advances in immunization led to major reductions in vaccine-preventable diseases in the past four decades, large gaps remain in the delivery of immunization services. In this perspective, we use illustrative examples to discuss gaps in global immunization and outline opportunities for evidence generation and intervention design to transform the last mile delivery of immunization services in global health. To address last mile gaps, technical limitations in global health surveillance infrastructure that result in imprecise estimates and overlapping obstacles that complicate immunization service delivery for selected groups need to be addressed. Additionally, leveraging pro-equity strategies from the community level to the global level and across phases of translational health research could accelerate the equitable impact of immunization innovations on population health outcomes.

The online version contains supplementary material available at 10.1186/s12913-026-14336-1.

Introduction: The paucity of data on perioperative outcomes in low- and middle-income countries complicates the design and implementation of targeted interventions to improve the delivery of safe, affordable, accessible and timely surgical and anaesthesia care services. We assessed perioperative outcomes of patients undergoing surgical care at three Rwandan rural hospitals—Butaro District Hospital, Kirehe District Hospital and Rwinkwavu District Hospital—supported by Partners In Health/Inshuti Mu Buzima—an international non-governmental organisation. Methods: We conducted a 6-month prospective observational cohort study at the three district hospitals. A validated electronic-based perioperative assessment tool was adapted for our setting to capture demographics and clinical information. Descriptive and logistic regression analyses were performed using Stata V.15.1. Results: A total of 3289 major surgeries were performed from January to September 2020 at the three hospitals. Overall, 3204 surgeries (97.5%) were performed on women; the median age was 27 years (IQR: 23–33), and emergency cases constituted 86.8% of all cases. Cases with the American Society of Anesthesiologists (ASA) status of 3 or above had higher odds of having surgical or anaesthesia complications compared with cases with ASA status 1 (OR: 11.1, 95% CI: 2.7 to 45.8). Furthermore, emergency cases had 1.8 times higher odds of having a composite outcome (developing complications, surgical site infections or death) compared with elective cases (95% CI: 1.1 to 3.0). Conclusion: Our findings highlight the need for improving surgical capacity, reinforcing infection prevention and control measures and leveraging electronic data capture for quality improvement to ensure safer surgery and anaesthesia care in rural Rwanda.

Background: Human Papillomavirus (HPV) is the primary cause of cervical cancer. Single-dose HPV vaccination can effectively prevent high-risk HPV infection that causes cervical cancer and accelerate progress toward achieving cervical cancer elimination goals. We modelled the potential impact of adopting single-dose HPV vaccination strategies on health and economic outcomes in Kenya, where a two-dose schedule is the current standard. Methods: Using a validated compartmental transmission model of HPV and HIV in Kenya, we evaluated the costs from the payer’s perspective to vaccinate girls by age 10 with either one or two doses and increasing coverage levels (0%, 70%, 77%, 90%). Additionally, we modelled single-dose strategies supplemented with either catch-up vaccination of adolescent girls and young women or vaccination for all by age 10, funded with the first five-years of cost savings of switching from a two- to one-dose schedule. Costs and outcomes were discounted at 3% annually, and incremental cost-effectiveness ratios (ICERs) were calculated per disability-adjusted-life-year (DALY) averted. Results: All one-dose and the two-dose 90% coverage strategies were on the efficiency frontier, dominating the remaining two-dose strategies. The two-dose 90% coverage strategy had a substantially higher ICER (US$6508.80/DALY averted) than the one-dose 90% coverage (US$197.44/DALY averted). Transitioning from a two- to one-dose schedule could result in US$21.4 Million saved over the first five years, which could potentially fund 2.75 million supplemental HPV vaccinations. With this re-investment, all two-dose HPV vaccination scenarios would be dominated. The greatest DALYs were averted with the single-dose HPV vaccination schedule at 90% coverage supplemented with catch-up for 11–24-year-old girls, which had an ICER of US$78.73/DALYs averted. Conclusions: Considering the logistical and cost burdens of a two-dose schedule, a one-dose schedule for girls by age 10 would generate savings that could be leveraged for catch-up vaccination for older girls and accelerate cervical cancer elimination in Kenya.

Adolescent girls and young women (AGYW) in southern Africa face triple the HIV incidence of their male peers due to multiple factors, including economic deprivation and age-disparate relationships. A new study by Aurélia Lépine and colleagues has demonstrated that addressing healthcare costs among AGYW has the potential to reduce HIV incidence.

Background: The World Health Organization recommends a single-dose human papillomavirus (HPV) vaccination schedule for girls and boys to accelerate progress toward cervical cancer elimination. We applied the Theoretical Framework of Acceptability (TFA) within the context of HPV vaccination to assess the acceptability of a single-dose schedule among health-care professionals in Kenya. Methods: A REDCap survey was developed using relevant Theoretical Framework of Acceptability domains and validated with health-care professionals. Descriptive analyses and multivariate Poisson regression were conducted to assess factors associated with increased acceptability. Free-text responses were analyzed using a rapid qualitative approach, and findings were presented using a joint display. Results: Among 385 responses, 74.2% of health-care professionals were female and 48.6% were nurses. On average, respondents had been in their position for 60 months, and one-third (33.2%) were based at level-4 facilities. The majority (75.84%) thought that giving a single-dose of the HPV vaccine to adolescent girls and young women was either acceptable or very acceptable. Qualitative findings highlighted that lack of information was the underlying reason for health-care professionals who were resistant, and most clinicians thought that a singled-dose schedule was less burdensome to clinicians and patients. Hospital directors had a non–statistically significantly lower acceptability likelihood than nurses (incident rate ratio = 0.93, 95% confidence interval = 0.45 to 1.71) and health-care professionals at urban facilities had a non–statistically significantly lower acceptability likelihood than clinicians in rural facilities (incident rate ratio = 0.97, 95% confidence interval = 0.83 to 1.13). Conclusion: Although not statistically significant, predictors of increased acceptability provide information to tailor strategies to increase HPV vaccination coverage and accelerate progress toward cervical cancer elimination.

Background: Cervical cancer is the leading cause of cancer-related deaths among Kenyan women. Persistent infection with high-risk oncogenic Human papillomavirus (HPV) genotypes is a necessary cause of cervical cancer. HPV vaccines are safe, durable, and efficacious in preventing incident HPV infections. In Kenya, despite efforts to increase HPV vaccination, coverage remains low. We sought to assess: (1) barriers and facilitators of HPV vaccination from the perspective of adolescent girls and young women (AGYW), their guardians as well as stakeholders involved in HPV vaccine delivery, and (2) the acceptability of the single dose of the HPV vaccination among healthcare providers (HCPs).Methods: Our study is nested within the KENya Single-dose HPV-vaccine Efficacy study (KEN SHE) that sought to test the efficacy of single-dose bivalent (HPV 16/18) and single-dose nonavalent (HPV 16/18/31/33/45/52/58/6/11) vaccination. We are conducting this study in Kiambu, Nairobi, and Kisumu counties. In these counties, we are interviewing stakeholders (n = ∼25), selected based on their role in HPV vaccination at the county and national levels. Interviews are audio recorded and conducted in English or Swahili. The semi-structured interview guides were designed based on: (1) the Theoretical Domains Framework (TDF) for AGYW and guardians and (2) the Consolidated Framework for Implementation Research (CFIR) for other stakeholders. The Theoretical Framework of Acceptability (TFA) was leveraged to design the survey administered to HCPs (n = ∼309) involved in HPV vaccination. We will develop a codebook based on emerging codes from the transcripts and constructs from the TDF and CFIR. Emerging themes will be summarized highlighting similarities and differences between and within the different stakeholder groups and counties. Descriptive statistics and a χ² test will be used to assess the distribution of responses between the different sites and regression analysis will be used to assess factors associated with high acceptability of the single-dose strategy while controlling for confounding variables.Discussion: Our study will describe key barriers and facilitators that affect HPV vaccination from the perspective of multiple stakeholders as well as insights on the perspective of HCPs towards the single-dose strategy to inform the designing of strategies to increase HPV vaccination uptake in Kenya and comparable settings.

Background: Moral distress and burnout are highly prevalent among oncology clinicians. Research is needed to better understand how resource constraints and systemic inequalities contribute to moral distress in order to develop effective mitigation strategies. Oncology providers in low- and middle-income countries are well positioned to provide insight into the moral experience of cancer care priority setting and expertise to guide solutions. Methods: Semistructured interviews were conducted with a purposive sample of 22 oncology physicians, nurses, program leaders, and clinical advisors at a cancer center in Rwanda. Interviews were recorded, transcribed verbatim, and analyzed using the framework method. Results: Participants identified sources of moral distress at three levels of engagement with resource prioritization: witnessing program-level resource constraints drive cancer disparities, implementing priority setting decisions into care of individual patients, and communicating with patients directly about resource prioritization implications. They recommended individual and organizational-level interventions to foster resilience, such as communication skills training and mental health support for clinicians, interdisciplinary team building, fair procedures for priority setting, and collective advocacy for resource expansion and equity. Conclusion: This study adds to the current literature an in-depth examination of the impact of resource constraints and inequities on clinicians in a low-resource setting. Effective interventions are urgently needed to address moral distress, reduce clinician burnout, and promote well-being among a critical but strained oncology workforce. Collective advocacy is concomitantly needed to address the structural forces that constrain resources unevenly and perpetuate disparities in cancer care and outcomes. Implications for Practice: For many oncology clinicians worldwide, resource limitations constrain routine clinical practice and necessitate decisions about prioritizing cancer care. To the authors’ knowledge, this study is the first in-depth analysis of how resource constraints and priority setting lead to moral distress among oncology clinicians in a low-resource setting. Effective individual and organizational interventions and collective advocacy for equity in cancer care are urgently needed to address moral distress and reduce clinician burnout among a strained global oncology workforce. Lessons from low-resource settings can be gleaned as high-income countries face growing needs to prioritize oncology resources.