Factors influencing neonatal male circumcision uptake among expecting couples in Zambia: formative findings.

Male circumcision is a protective HIV prevention strategy. However, uncircumcised Zambian men are reluctant to undergo voluntary medical male circumcision (VMMC). Tailored interventions are necessary to stimulate the uptake of early infant male circumcision (EIMC) and VMMC in Zambia. This feasibility study presents the formative process of utilising the PRECEDE framework in the development of a family-centred EIMC/VMMC intervention, Like Father Like Son, and its application in an existing VMMC intervention, Spear & Shield. We found that fear of the pain associated with EIMC procedures, foreskin disposal, beliefs in children's autonomy and rights, and men's dominance in health decision-making were factors affecting EIMC uptake. Perceived benefits for infants included improved hygiene, protection from HIV infection, and faster recovery. Reinforcing factors included female partners and fathers' MC status. The availability and access to EIMC services and information, skill and experience of health workers, and engagement and belief in traditional circumcision practices were factors enabling EIMC uptake. These individual, interpersonal, and structural factors positively and negatively influencing EIMC uptake in the Zambian clinic context were integrated into the intervention for expecting parents. Feedback from community advisory boards suggested the process was effective in developing a culturally tailored and acceptable EIMC/VMMC promotion intervention.

Exploring The Challenges Faced by Informal Home Based Palliative (HBP) Caregivers in Ndola District, Zambia.

In order to explore informal Home-based palliative caregivers' challenging experiences, this study gives an overview of the need of Home-based palliative caregivers in communities. Dialogs using In-depth interviews (IDI's) with twenty-five (25) purposively and conveniently selected respondents aged 18 years and over were conducted. They were not professional caregivers but volunteers from within the community attached to health facilities in Ndola. Discussions on global, Africa and Zambian' situations, and Ndola in particular were included. The findings, using thematic analysis, were lack of supporting resources, inadequate coordination, lack of training, undesirable working conditions and unreliable transport network. The study will facilitate formulation of guiding principles and policies for palliative care practices through recommendations based on results from this study to improve and sustain palliative care services.

Black Lives Matter in health promotion: moving from unspoken to outspoken.

Racism is a public health crisis. Black communities (including Africans, the African diaspora and people of African descent) experience worse health outcomes as demonstrated by almost any measure of health and wellbeing-e.g. life expectancy; disease prevalence; maternal mortality rates. While health promotion has its foundation in promoting equity and social justice, it is clear that however well-intended, we are not affecting meaningful change for Black communities quickly enough. Through this article, we outline the intersection of social determinants of health and anti-Black racism. We describe how in the first 8 months of 2020 Black communities around the globe have been disproportionately affected by COVID-19, while also having to respond to new instances of police brutality. We assert that the time has come for health promotion to stop neutralizing the specific needs of Black communities into unspoken 'good intentions'. Instead, we offer some concrete ways for the field to become outspoken, intentional and honest in acknowledging what it will take to radically shift how we promote health and wellbeing for Black people.

A health promotion approach to emergency management: effective community engagement strategies from five cases.

Community engagement is crucial for controlling disease outbreak and mitigating natural and industrial disasters. The COVID-19 pandemic has reconfirmed the need to elevate community engagement to build equity, trust and sustained action in future health promotion preparedness strategies. Using the health promotion strategy of strengthening community action enhances the opportunity for better outcomes. There is, therefore, a need to improve our understanding of community engagement practices during crises, scale-up good community engagement initiatives, and improve and sustain people-centered approaches to emergency responses. This paper presents five case studies from the United States, Singapore, Sierra Leone, Kenya and South Africa that demonstrate the potential strengths that can be nurtured to build resilience in local communities to help mitigate the impact of disasters and emergencies. The case studies highlight the importance of co-developing relevant education and communication strategies, amplifying the role of community leaders, empowering community members to achieve shared goals, assessing and adapting to changing contexts, pre-planning and readiness for future emergencies and acknowledgement of historic context.

Exploring the Gender-Specific Impact of Educational Film on Maternal and Child Health Knowledge and Behavior: A Qualitative Study in Serenje District, Zambia.

BACKGROUND: Educational film is a communication tool that helps to present complex information simply and clearly, keeping audiences interested for longer and helping to reinforce important learning. Medical Aid Films produces educational films targeted at communities and health workers, with a focus on maternal and child health (MCH) content. Pilot work suggests that film screenings have attracted male as well as female viewers and have started to increase male involvement in MCH care. We explored stakeholder perspectives and gender-specific responses to educational films screened in a rural district of Serenje, Zambia. METHODS: A qualitative study using focus group discussions and in-depth interviews with men and women who had viewed the films at least once, and key informant interviews with health workers who helped deliver the film screenings. Thematic framework analysis was used to derive themes and subthemes, and illustrative quotes are used to substantiate interpretation of the findings. RESULTS: Men's and women's perspectives are clustered around the influence of the films on knowledge and behavior in relation to MCH topics and male involvement and overall community responses to the films. The three themes summarizing key informant perspectives relate to their impressions of the influence of the films on male involvement in MCH and their views on using film to deliver heath information. CONCLUSION: Educational films have the potential to improve women's and men's knowledge and awareness of MCH topics, including healthy nutrition and welfare of women during pregnancy, the need to seek skilled care during pregnancy and for childbirth, and the importance of male involvement in supporting the care of women and children. Before widespread implementation, decisions must be made about whether and how to integrate the films with community health education programs, the needs, values, and preferences of men and women and how to present and deliver the film content in a way that maximizes participation of men and women in MCH but does not undermine women's rights, autonomy, or safety.

"They say that I have lost my integrity by breaking my virginity": experiences of teen school going mothers in two schools in Lusaka Zambia.

BACKGROUND: Adolescent school-going mothers return to school in the rekindled hope of obtaining an education. However, their re-introduction into the school environment requires adequate support from teachers, fellow pupils, and the community. The purpose of this study was to explore the experiences of school-going mothers in Lusaka to understand their coping mechanism in the process of re-integration. METHOD: This is a qualitative case study. We conducted in-depth interviews with 24 school going mothers between the ages of 16-19, purposively selected from 2 schools in Lusaka district. Audio-recorded interviews were transcribed, coded using Nvivo 10 software and analysed using thematic analysis. RESULTS: The girls reported experiencing stigmatization, discrimination, mockery and abuse from their teachers. Some community members labelled, humiliated, gossiped about and isolated the girls from their friends and classmates because of fear of 'contamination'. Families forced some girls into early marriages making them feel rejected. These experiences resulted in low self-esteem, inferiority complex, poor performance in their academic work and identity crises in the young mothers. Therefore, because of the experiences the girls faced, they developed certain behaviours such as beer drinking, truancy and running away from home. They found it difficult to adjust to motherhood while doing their schoolwork. CONCLUSION: There is a need for the teachers to undergo training on how to handle young mothers and have a flexible time-table to accommodate adolescent school going mothers when they miss lessons to attend to their babies. Non-parenting school girls should be counseled so that they do not stigmatize adolescent mothers. Parents need to be educated on how to deal with adolescent mothers in the community. The guidance office should have a qualified psychosocial counselor to help create a conducive learning environment for adolescent mothers, by helping them with missed lessons and seeing to it that they are not stigmatized.

Men's perspectives on male participation in antenatal care with their pregnant wives: a case of a military hospital in Lusaka, Zambia.

BACKGROUND: Male partner participation in antenatal care (ANC) is important and contributes to better maternal and neonatal birth outcomes. Studies have been conducted to explore male participation in ANC and barriers to participation. However, these studies have been conducted in the general population and not the military settings, which are gendered institutions. This study aimed to explore the perspectives of male participation in ANC in a military setting. METHODS: A qualitative case study approach using convenient sampling was used to enlist sixteen (n = 16) military men whose partners or wives were attending ANC. In-depth interviews were conducted with participants to get their perspectives on their participation in ANC. The interviews were transcribed verbatim and codes, categories and themes were generated from the data. Data analysis was done manually and was guided by thematic framework analysis approach. We designed a table which listed all emerging themes, categories and sub-themes. RESULTS: Participants were aged 27-45 years and some attained tertiary education. Five themes emerged to explain the perspectives of male participation in ANC. Men's roles were perceived to be limited to provision of appropriate food and supplies, physical and emotional support. Generally, ANC attendance was considered a woman's private activity because even health care providers were mostly female. However, the desire to have a healthy baby prompted many to seek information on ANC. On the other hand, priority given to couples attending ANC and the need to be part of the decision making motivated some to participate. For the participants in this study, military operations, fear of being tested for HIV and the belief that presence of men in ANC interferes with care made them shun the services. CONCLUSION: Lack of awareness on the importance of male participation in ANC impacted on the understanding of access and use of services by participants. The study has practical implications in the military institution to formulate policy on male participation in ANC to improve maternal and newborn health outcomes as well as support staff who have to attend to their pregnant wives or partners.

Contemporary issues in north-south health research partnerships: perspectives of health research stakeholders in Zambia.

BACKGROUND: The late 1990s and early 2000s have seen a growth in north-south health research partnerships resulting from scientific developments such as those in genetic studies and development of statistical techniques and technological requirements for the analysis of large datasets. Despite these efforts, there is inadequate information representing the voice of African researchers as stakeholders experiencing partnership arrangements, particularly in Zambia. Furthermore, very little attention has been paid to capturing the practice of guidelines within partnerships. In this paper, we present achievements and highlight challenges faced by southern partners in north-south health research partnerships. METHODS: A qualitative inquiry was employed using in-depth interviews developed using the Bergen Model of Collaborative Functioning with 20 key informants in Lusaka district in Zambia purposively sampled from a wide range of health research partnerships. RESULTS: Partnerships produce benefits for southern partners, including evidence generation to influence policy, improved service delivery, infrastructure development and designing interventions to improve the healthcare of populations in greatest need. Most importantly, through partnerships, there is availability of financial resources to accomplish partnership goals. For success to be achieved, there must be effective communication and leadership, values and accountability that go into the process of partnership functioning. Trust interacts with different elements that create partnerships where there is co-ownership of study rewards. Challenging aspects of the interaction are largely due to funding mechanisms where 90% of the funding for health research is from northern partners. This funding mechanism results in power imbalances that lead to publication challenges, dictation of research agenda and ownership of samples and data leading to a general lack of motivation to collaborate. CONCLUSION: Mistrust has implications on joint working such that partners find it difficult to work together and produce results greater than their individual efforts. Property rights and resource sharing must be resolved early in the partnership and each partner's contributions recognised. These findings highlight areas that partnerships need to focus on to make the most of guidelines on research partnership with developing countries.

Social and clinical attributes of patients who restart antiretroviral therapy in central and Copperbelt provinces, Zambia: a retrospective longitudinal study.

BACKGROUND: About 30% of the patients initiated on antiretroviral therapy in Zambia default treatment. Some of these patients later restart treatment; however, the characteristics of these patients have not been well described and documented. The aim of this study was to describe and document the socio-demographic and clinical characteristics of patients who default and restart antiretroviral therapy, and to determine the socio-demographic characteristics associated with CD4 count response at 6 and 24 months of restarting antiretroviral therapy. METHODS: A longitudinal retrospective analysis was performed on data from 535 adult patients restarting antiretroviral therapy in 2009 and 2010 at five antiretroviral therapy centres in Copperbelt and Central provinces of Zambia. To determine the association between the socio-demographic characteristics and CD4 cell count, quantile regression models were used. RESULTS: Older age above 45 years was associated with a significantly lower CD4 cell response by 38.1 cells/mm(3) (95% Confidence interval [CI]: -109.4 to -0.2) compared to the younger age (15-29 years). Patients in formal employment (Adjusted Coefficient [AC] 29.5, 95% CI: 22.8 to 81.1) and self-employment (AC 48.1, 95% CI: 18.6 to 77.4) gained significantly higher CD4 cells than those unemployed. In addition, baseline CD4 count, type of treatment, WHO staging, total duration on treatment and duration lost to follow-up were found to be strong predictors of CD4 cell count at 6 and 24 months after restarting antiretroviral therapy treatment. CONCLUSION: Age and occupation were the only socio-demographic characteristics predicting CD4 count in the patients at 6 months after restarting antiretroviral therapy after adjusting for other confounding clinical variables.

"When am I going to stop taking the drug?" Enablers, barriers and processes of disclosure of HIV status by caregivers to adolescents in a rural district in Zambia.

BACKGROUND: Disclosure of adolescents' own HIV status by caregivers is not only challenging but low. The reasons for this remain unclear despite efforts to examine and seek to understand disclosure patterns or factors that may either facilitate or inhibit this disclosure. This study explored the enablers, barriers and processes of disclosure of HIV status to adolescents by their caregivers in Kafue district of Zambia. METHODS: A case study method was used to understand factors that facilitate or inhibit caregiver's ability to disclose the HIV status of adolescents aged 10-15 years. Data collected through in-depth interviews with 30 caregivers as well as 6 key informants were analysed using thematic analysis. RESULTS: Overall, 17 out of 30 (56.7 %) caregivers had informed the adolescents about their HIV status. Reasons for disclosing of the HIV status included inquiries by adolescents as to why they were taking medication, threats by adolescents not to take HIV medication, desire to promote treatment self-efficacy amongst adolescents as well as facilitating adoption of safe sexual behaviour among adolescents. The disclosure processes were conducted either at the home or at the clinic. Enabling factors for HIV disclosure were adolescents' knowledge of HIV and caregivers' knowledge of and experience with HIV programs. Barriers to disclosure of HIV status included fear of psychological trauma for the adolescents, perceived inability of adolescents to keep their HIV status confidential which could attract HIV stigmatisation for the family, and caregivers', fear of being blamed by the adolescents for the infection, limited disclosure skills by caregivers as well as negative attitude by some HIV counsellors. CONCLUSIONS: Despite challenges associated with disclosure of adolescents' own HIV status by caregivers, environments that facilitate this process exist and can be strengthened. Promoting HIV disclosure requires in-depth and context-specific understanding of the factors that enable and undermine this process. Limitations in this understanding may have played critical roles in past strategic implementation of locally driven and relevant interventions to improve disclosure of HIV status by caregivers to adolescents in Zambia.

HIV, syphilis and sexual-risk behaviours' prevalence among in-and out-of-school adolescent girls and young women in Zambia: A cross-sectional survey study.

BACKGROUND: In Zambia, 3.8% of young women and men aged 15-24 are HIV positive. However, like in most developing nations, HIV prevalence is higher among young women than young men (5.6% versus 1.8%). Despite the recognition of the rights of young people to sexual reproductive health (SRH) information and services, adolescent and young people (AYP) still face challenges in accessing healthcare in public health institutions including access to comprehensive knowledge on HIV/AIDs, HIV testing and contraceptives. The overall objective of the study was to collect baseline HIV, SRH and gender based violence (GBV) data at district level to inform the design of interventions targeting adolescent girls and young women (AGYW) aged 10-24 years in 20 districts of Zambia. METHODS: A cross-sectional, mixed-methods study was conducted in 20 districts of Zambia with the highest incidence of HIV. Data was collected between August and October 2022 with a total response rate of 92% (12,813/13960), constituting 5979 (46.7%) in-school and 6834 (53.3%) out-of-school participants. RESULTS: Overall, Mwinilunga, Chinsali, Chisamba and Chembe districts had the highest number of respondents, while Sinazongwe and Mungwi districts contributed the least. The overall age distribution was such that 12.6% (n = 1617) of those interviewed were aged 10 to 14 years, 35.4% (n = 4536) were aged 15-19 years, and 52.0% (n = 6660) were aged 20-24 years. The overall mean age at first sex among AGYW interviewed was 16.6 years which was broken down as follows: 16.2 years for in-school and 16.8 years for out of school. Overall, most of the respondents had first time sex with either their boyfriend (80.4%) or husband (15.6%), with 2.4% of the in-school participants reporting to have had their sexual debut in marriage compared to 21.0% among out-of-school AGYW. Prevalence of HIV was higher in the out-of-school compared to the in-school participants (5.5% vs 2.0%), Similarly, the prevalence of syphilis was higher in the out-of-school than the in-school participants (4.1% vs 1.5%). CONCLUSION: The study focused on assessing the prevalence and vulnerability of HIV, syphilis, GBV, and SRH services uptake among adolescent girls and young women, and exploring factors affecting girls' stay-in-school and re-engagement. The study found that HIV and syphilis are still significant public health problems among adolescent girls and young women in Zambia, emphasizing the need for increased efforts to prevent and manage these infections.

Evaluating a multifaceted implementation strategy and package of evidence-based interventions based on WHO PEN for people living with HIV and cardiometabolic conditions in Lusaka, Zambia: protocol for the TASKPEN hybrid effectiveness-implementation stepped wedge cluster randomized trial.

BACKGROUND: Despite increasing morbidity and mortality from non-communicable diseases (NCD) globally, health systems in low- and middle-income countries (LMICs) have limited capacity to address these chronic conditions, particularly in sub-Saharan Africa (SSA). There is an urgent need, therefore, to respond to NCDs in SSA, beginning by applying lessons learned from the first global response to any chronic disease-HIV-to tackle the leading cardiometabolic killers of people living with HIV (PLHIV). We have developed a feasible and acceptable package of evidence-based interventions and a multi-faceted implementation strategy, known as "TASKPEN," that has been adapted to the Zambian setting to address hypertension, diabetes, and dyslipidemia. The TASKPEN multifaceted implementation strategy focuses on reorganizing service delivery for integrated HIV-NCD care and features task-shifting, practice facilitation, and leveraging HIV platforms for NCD care. We propose a hybrid type II effectiveness-implementation stepped-wedge cluster randomized trial to evaluate the effects of TASKPEN on clinical and implementation outcomes, including dual control of HIV and cardiometabolic NCDs, as well as quality of life, intervention reach, and cost-effectiveness. METHODS: The trial will be conducted in 12 urban health facilities in Lusaka, Zambia over a 30-month period. Clinical outcomes will be assessed via surveys with PLHIV accessing routine HIV services, and a prospective cohort of PLHIV with cardiometabolic comorbidities nested within the larger trial. We will also collect data using mixed methods, including in-depth interviews, questionnaires, focus group discussions, and structured observations, and estimate cost-effectiveness through time-and-motion studies and other costing methods, to understand implementation outcomes according to Proctor's Outcomes for Implementation Research, the Consolidated Framework for Implementation Research, and selected dimensions of RE-AIM. DISCUSSION: Findings from this study will be used to make discrete, actionable, and context-specific recommendations in Zambia and the region for integrating cardiometabolic NCD care into national HIV treatment programs. While the TASKPEN study focuses on cardiometabolic NCDs in PLHIV, the multifaceted implementation strategy studied will be relevant to other NCDs and to people without HIV. It is expected that the trial will generate new insights that enable delivery of high-quality integrated HIV-NCD care, which may improve cardiovascular morbidity and viral suppression for PLHIV in SSA. This study was registered at ClinicalTrials.gov (NCT05950919).

Psychosocial challenges and coping strategies among people with minority gender and sexual identities in Zambia: health promotion and human rights implications.

Background: Sexual and gender minorities face high levels of stigma, discrimination, and violence. In many countries, they are often criminalized and are at risk of mental health challenges. In Zambia, little is known about the psychosocial challenges and coping strategies of sexual and gender minorities. This study sought to explore psychosocial challenges and coping strategies among sexual and gender minority populations in Lusaka, Zambia to inform mental health and human rights promotion for this population. Methods: The study used a qualitative phenomenological study design. Data were collected through in-depth interviews with 16 sexual and gender minority participants (lesbian, gay, bisexual, and transgender) and four key informants. The sexual minorities included four lesbian, five gay, and three bisexual participants while the gender minorities included two transgender men and two transgender women. Interviews with gender and sexual minorities were mostly focused on the lived experiences of participants, while those of key informants focused on their work with sexual and gender minorities. Snowball strategy was used to recruit participants, while purposive sampling was used to select key informants. All interviews were recorded and transcribed verbatim. Thematic analysis was carried out with the aid of Nvivo 12 software. Results: Psychosocial challenges included victimization in the form of threats and physical assault. Stigma and discrimination were experienced in different settings such as healthcare, the workplace, and school. Participants reported having experienced feelings of depression. Rejection from family members was experienced by those who revealed their sexual or gender minority status. Reported coping strategies included social support, self-concealment, listening to music, and substance use. Conclusion: This study suggests that sexual and gender minorities in Zambia experience various psychosocial challenges related to their sexuality and gender identity. To assist them cope better with the obstacles they experience, improved psychosocial counseling and mental health services are needed.

Perspectives and experiences of Zambian pregnant and postpartum women receiving two intervention models to increase uptake of male partner HIV testing.

This study explored the experiences of pregnant women who received two intervention models for increasing uptake of male partner HIV testing in antenatal settings. As part of a randomised trial, we interviewed twenty participants who received partner notification services only while 22 received the partner notification plus HIV self-testing. Thematic analysis was used to analyse the data. Partner notification services helped to initiate discussions of HIV testing with partners, influence partners to undergo testing, and encouraged disclosure of HIV status. Some women experienced difficulties engaging partners due to fear of their partner's reaction. Some partners were unable to test due to time constraints. The partner notification plus HIV self-testing intervention, stimulated discussion about HIV testing; facilitated testing for men at their convenience; addressed privacy/confidentiality, and stigma concerns; and provided the opportunity to disclose HIV status. Some women feared disclosure and retribution in case of discordance results. There were also challenges with men making follow-ups for confirmatory HIV tests. The addition of HIV self-test kits to partner notification services can expand HIV testing services to male partners, including those of HIV-negative women. Additional efforts are needed to link men to appropriate HIV prevention, care, and treatment services.

Increasing early infant male circumcision uptake in Zambia: Like father like son.

Voluntary Medical Male Circumcision (VMMC) is an effective strategy for HIV prevention in areas with high prevalence of, and risk for, HIV. More than 361,000 male neonates are born each year in Zambia, many of whom could be eligible for Early-Infant Medical Circumcision (EIMC). Building on successful implementation strategies utilized in our Spear & Shield program, this pilot study, "Like Father, Like Son" (LFLS), evaluated the feasibility and acceptability of offering combined EIMC and VMMC services and couple-level behavioral interventions. A total of N = 702 pregnant women and their male partners (n = 351 couples) were recruited and enrolled. Couples were assessed twice pre-birth, 2 weeks post birth, and 6 months post birth. Expectant mothers were an average of 15.05 weeks pregnant (SD = 8.83). Thirty-nine pregnancies did not result in a live birth (11%), 14 couples withdrew from the study or were lost to follow-up prior to delivery (4%), and 148 babies were born female (42%), leaving 150 couples with a male infant in the analytic sample (43%). The LFLS study achieved significantly higher EIMC rates (35%) in comparison with previously observed EIMC study rates in Zambia (11%), and significantly higher than hypothetical comparison rates up to 30%. Relative to baseline rates, odds of VMMC among couples' older sons increased by 31% at post-intervention and by 90% at two-weeks following birth. Overall, this pilot study found the LFLS intervention to be feasible, acceptable, and effective in doubling the rate of EIMC in comparison with a previous longitudinal study in Zambia. Future research should consider a family-centric approach to promotion of male circumcision for infants and adolescents. LFLS may be effective in promoting father-son "bonding" by MC status; a bond that may be a bridge to increase both EIMC and VMMC uptake in newborns and couples' older sons and is a novel leverage point for promotion of this HIV prevention strategy.

Contextualising men's role and participation in PMTCT programmes in Malawi and Zambia: A hegemonic masculinity perspective.

This study sought to explore and contextualise the man's role in antenatal services, and the barriers and strategies for engaging men in prevention of mother-to-child HIV transmission (PMTCT). We conducted 143 interviews with pregnant and breastfeeding women, male partners, health workers and policy makers in Malawi and Zambia. We employed thematic and critical discourse analysis using the hegemonic masculinity perspective. We found that men's roles in PMTCT reflected hegemonic masculinities. As breadwinners, men supported their partners with material and financial resources. As decision makers, men were involved in decision making on the health of their partners. As social protectors, men supported their partners in accessing and adhering to antenatal care, HIV treatment and care. Barriers and challenges to male involvement in antenatal care were often the result of conflict between the clinic operating hours and men's working hours, the perception of antenatal care services as female spaces, and men's fear of HIV testing. Proposed strategies to increase male engagement in PMTCT included sensitising men about HIV and pregnancy; engaging leaders and employers, providing services outside working hours, and providing incentives. We conclude that men's role and participation in PMTCT services are an extension and adaptation of hegemonic masculinities.

Acceptability of the human papillomavirus vaccine in schools in Lusaka in Zambia: Role of community and formal health system factors.

Zambia has one of the highest cervical cancer rates in the world. This paper explores the acceptability of the Human Papillomavirus vaccine administered in girls (9-13 years) in Zambia. A qualitative case study was conducted in two schools in Lusaka district, which participated in the pilot for the Human Papillomavirus vaccine rollout. The study revealed that community level health systems factors such as knowledge levels about the vaccine, sexual morality concerns, conflicting views from parents on the vaccine, rumours that the vaccine contained cervical cancer and that it causes infertility in girls, previous bad experience with other vaccines, religious beliefs such as belief that God protects against illness, the nature of the school environment as well as faith in doctors shaped the uptake of the vaccine. Furthermore, formal health system factors such as availability of health workers and nature of collaboration between the Ministries of Health and Education influenced acceptability of the vaccine among the girls. Strengthening collaboration between community and formal health systems can play a vital role in supporting uptake of vaccines at community level as factors that hinder uptake of the vaccines emanate from both the community and health sector.