Beyond campaigns: a national mixed-methods study on advancing routine HPV vaccination in Lesotho

Background Lesotho has historically delivered human papillomavirus (HPV) vaccination through school-based campaigns, achieving high uptake of the first dose but lower completion of subsequent doses. This study assessed HPV vaccination coverage, dropout rates, documentation practices and the behavioural and social drivers (BeSD) of uptake to inform the transition towards routine HPV vaccination. Methods A nationally representative mixed-methods survey was conducted in 2024. The quantitative component involved visits to 5111 households and identifying 279 eligible girls aged 9–17 years. Data were collected on receipt of HPV dose 1 and dose 2, availability of vaccination cards and caregiver knowledge. Additionally, 15 key informant interviews were conducted with adolescent girls, caregivers and service providers in Butha-Buthe and Quthing to explore barriers to communication, trust and access. Weighted survey estimates and logistic regression were used for quantitative analysis, while qualitative data were analysed thematically using the WHO BeSD framework. Results HPV dose 1 coverage was 85%, while dose 2 coverage was 52.9%, reflecting a 32% dropout rate. In-school girls had higher completion rates than out-of-school girls. Caregiver education and trust in health workers were strong predictors of vaccine uptake. Only 43% of vaccinated girls were able to present a vaccination card. Qualitative findings highlighted communication gaps in follow-up doses, limited access for out-of-school girls due to school-based delivery, and the significant role of trust in health workers as a key factor influencing vaccine acceptance. Conclusion High uptake of HPV dose 1 demonstrates strong acceptance; however, substantial dropout and inequities persist, particularly among out-of-school girls. Strengthened communication, improved documentation and expanded delivery strategies are needed. Integrating HPV vaccination into routine primary healthcare and adopting the WHO-recommended single-dose schedule could enhance equitable coverage and support cervical cancer elimination efforts in Lesotho.