Community Health Workers: The Key to HPV Vaccination Success With Adolescent Girls in Malawi

In 2019, the Malawi Ministry of Health and Population introduced the human papillomavirus (HPV) vaccine, the most cost-effective public health measure to prevent HPV and cervical cancer, with a focus on adolescent girls. In 2020, 4,145 women were diagnosed with cervical cancer, which can result from untreated HPV. Health surveillance assistants (HSAs) have been critical to reaching girls across the country with the vaccine.

HSAs, of whom there are more than 11,000 in Malawi, have a significant role in planning and implementing community health interventions, from family planning to immunization. Much of their HPV prevention work involves emphasizing the importance of vaccination; dispelling misconceptions and answering questions about the vaccine; mobilizing parents and community leaders to promote vaccination among adolescent girls, and collaborating with teachers to deliver the vaccine through schools. Given the country’s plan to administer HPV vaccine to girls throughout the year—and the challenges posed by the COVID-19 pandemic—the HSAs are ever more vital. 

So far, 20 of Malawi’s 29 districts have started to deliver the HPV vaccine through the routine immunization system (i.e., on a continuous basis as each girl turns 9 years old). In these districts, HSAs have increased the frequency of their vaccination and community engagement sessions, promoting the vaccine for cancer prevention, reminding girls when it’s time for their second dose, and updating communities on the country’s approach to delivering the vaccine. Furthermore, with schools closed due to the COVID-19 pandemic and teacher sit-ins in some districts, HSAs have taken on a more prominent role, identifying girls eligible for their first dose of the vaccine and encouraging them to get vaccinated, a role they would usually share with teachers.

Beyond the multiple efforts and activities, HSAs’ work can be challenging. In Chitipa, for example, there was widespread hesitancy about the HPV vaccine due to misconceptions about its effect on fertility and reproductive health (it has none). HSAs organized communication activities, including plays and community meetings, to dispel rumors and convey information about how the vaccine can prevent cervical cancer.

These efforts have led to changes in perception and improved both HPV vaccine acceptance and coverage in Chitipa. HSAs note that many mothers now take their daughters to be vaccinated rather than keeping them home from school on days vaccination is planned. The numbers back up their observations: as of May 2021, 65 percent of girls in Chitipa had received a second dose of the HPV vaccine, representing the vaccination of approximately 2,500 of 3,835 girls eligible in the cohort for their second dose. To sustain this success, HSAs have created their own support system to share best practices and lessons for improving vaccine acceptance.

HSAs’ role in community engagement has been critical for the introduction and routinization of the HPV vaccine and became even more important as the COVID-19 pandemic caused school closures and interrupted adolescent health programs. The HSAs in Malawi have shown that consistent communication with leaders, educators, parents, and girls can increase HPV vaccine acceptance. To protect more girls from HPV and cervical cancer in Malawi and across the globe, we must dedicate more financial resources and attention to community-based engagement.

Written by Patrick Nicks, Hannah Hausi, Kate Bagshaw, and Nicole Davis

Learn more about our work to support HPV vaccine introduction in Malawi and seven other countries.