Her health, her choice: a PEN-3 exploration on facilitators, and preferences for HPV vaccinations and HPV self-collection among Nigerian girls and women

Introduction

Globally, cervical cancer is the fourth most common cancer among women, with an estimated 662,000 new cases and 349,000 deaths reported in 2024 (1). In Nigeria, it is the second most common cancer in women, contributing approximately 15,000 new cases and nearly 10,000 deaths annually, highlighting the country as a critical priority for prevention and control efforts (2). Human papillomavirus (HPV), the primary etiologic agent of cervical cancer, is a common sexually transmitted infection with more than 100 genotypes, including 13 high-risk types linked to cervical carcinogenesis. HPV types 16 and 18 alone account for about 70% of cervical cancer cases globally (3). Persistent infection with high-risk HPV can progress to precancerous lesions, invasive cervical cancer, and ultimately death (4).

HPV prevalence among Nigerian women ranges from 20% to 40%, with rates varying significantly by age (5). In addition, limited awareness of HPV, its risk factors, and its role in cervical carcinogenesis contributes to the country's high incidence and mortality from cervical cancer (3). Early detection through screening, such as Pap smears and HPV testing, is essential, as these methods identify precancerous changes before they progress to invasive disease (6). HPV self-collection has emerged as an essential screening option in many low- and middle-income countries, offering a convenient, private, and empowering alternative to clinic-based pelvic examinations (7). Evidence demonstrates that HPV self-collection is equally effective at detecting high-grade cervical precancer and can substantially increase screening uptake (8). HPV vaccination continues to be a key element in primary prevention for adolescents who are eligible by age, lowering the risk of HPV infection and cervical cancer by as much as 90% (9, 10).

Despite the proven benefits of HPV vaccinations, cervical cancer screening, and HPV self-collection, uptake in Nigeria remains low. Only 8.7% of women aged 18–69 have ever been screened, mainly due to limited awareness, cultural beliefs, stigma, and inadequate access to affordable services (11). HPV self-collection, though promising, is still emerging, underutilized, and constrained by low awareness, limited self-efficacy, minimal provider recommendations, and scarce kit availability (7). In contrast, Nigeria recently achieved 71% first-dose HPV vaccination coverage among girls aged 9–14, immunizing nearly 12 million girls (12). Persistent barriers to HPV vaccination and screening include myths and misconceptions, concerns about safety and side effects, stigma surrounding sexually transmitted infections, religious and social norms, and structural challenges such as cost, distance, and service availability (8). Evidence shows that cultural values strongly shape parental acceptance of HPV vaccination (13); many African parents perceive their daughters as low-risk due to expectations of abstinence, while others fear that vaccination may promote premarital sexual activity, highlighting broader silence around sexual health (14, 15).

Addressing barriers to cervical cancer prevention requires comprehensive, sustainable, culturally sensitive strategies that include educational campaigns and community programs, which are then integrated with existing healthcare services. Nonetheless, most research on cervical cancer prevention and decision-making has been carried out in high-income countries, where health systems, social dynamics, and contextual factors differ significantly from those in Nigeria and other low-resource settings (16). Few studies have explored the overlapping cultural, relational, and structural influences on prevention choices among Nigerian girls and women, especially those pertinent to mother–daughter dyadic interventions. Recognizing sociocultural and health system factors can guide the development of targeted interventions, facilitate informed decision-making, increase engagement in cervical cancer prevention, and reduce the disease burden (17).

While HPV vaccination and self-sampling target different decision-makers, parents or caregivers for adolescent girls and women for themselves, they are interconnected in cervical cancer prevention, facing overlapping barriers like misinformation, stigma, access, and affordability (18, 19). However, few studies, particularly in LMICs, have explored these shared influences. Understanding these factors is essential for designing culturally sensitive dyadic interventions involving mothers and daughters, which offer insights into how sociocultural norms, family, and community shape prevention choices, inform strategies that empower women and girls, and improve screening and vaccination uptake. To address this gap, our study aims to: (1) explore the perceptions, facilitators, and barriers related to cervical cancer screening, HPV self-collection, and HPV vaccination for adolescent children among Nigerian girls and women; and (2) examine Nigerian women's preferences for these prevention interventions.

Methods

Study design

Using purposive sampling, this qualitative study conducted semi-structured, in-depth interviews with women and girls in Lagos, Nigeria. We applied the Consolidated Criteria for Reporting Qualitative Research (COREQ) to ensure rigorous and transparent reporting of study design, recruitment, data collection, and analysis (20). Guided by the PEN-3 cultural model (21), we conducted a thematic analysis to identify relational, sociocultural, and structural factors influencing girls' and women's uptake of HPV vaccination and HPV self-collection.

Conceptual framework

The PEN-3 cultural model provides a culturally grounded approach to understanding health behavior by emphasizing collective and contextual influences. Airhihenbuwa (1995) organizes the PEN-3 model into three domains: Cultural Identity, Relationships and Expectations, and Cultural Empowerment (22). The Cultural Identity domain includes Persons, Extended Families, and Neighborhoods, highlighting the roles of individuals and familial/community support in health decisions. For example, younger participants rely on parental consent, while older women's decisions are influenced by spousal approval and community norms. Moreover, individual characteristics such as self-efficacy, training, and awareness increase women and girls' use of self-collection and vaccination. Barriers like knowledge gaps, beliefs, social norms, and misconceptions can hinder engagement and vaccine uptake (24).

The Relationships and Expectations domain covers Perceptions (e.g., beliefs about HPV vaccine safety), Enablers (e.g., access to trusted providers, availability of self-collection HPV kits), and Nurturers (e.g., family, peers, policy, and healthcare infrastructure), all of which influence HPV vaccination and self-collection (22). While the Cultural Empowerment domain assesses contextual factors that are Positive, Existential, or Negative. Positive includes community support for vaccination; existential pertains to unique cultural practices; negative involves stigma and misinformation, which require targeted interventions (22). This offered a comprehensive view of socio-cultural and systemic influences, as well as knowledge, beliefs, and experiences regarding HPV prevention and HPV self-collection, ensuring interventions align with community values and address systemic issues (23).

Study setting

The study was conducted in Lagos State, located in Southwest Nigeria, with an estimated population of about 21 million. Lagos State consists of 20 Local Government Areas, with 16 classified as urban and 4 as rural. There are 2,196 health facilities in the state, categorized into primary (n = 1,475), secondary (n = 714), and tertiary (n = 7) levels. Lagos State has a high rate of cervical cancer (26). However, cervical cancer screening services are available at a few tertiary health centers and are not accessible in all states of the country. Some government and private hospitals and diagnostic centers offer limited screening (27). To address service gaps, various organizations conduct outreach programs for community and rural screening. In Lagos' diverse urban context, it is relevant to understand the contextual factors influencing cervical cancer prevention behavior.

Study population

The study involved 56 selected female participants, divided into two age groups: girls aged 9–26 years and women aged 30–65 years. The “younger” group (9–26 years) included adolescent girls and young women who may still benefit from HPV vaccination. The “older” group (30–65 years) comprises women and adult caregivers for whom screening through HPV self-collection and cervical cancer prevention are more relevant. This categorization shows predefined analysis groups; women aged 27–29 were not intentionally excluded. Participants were recruited through purposive sampling from community-based settings, including schools, marketplaces, churches, mosques, and health facilities. Eligible participants were female residents of Lagos State aged 9–65 years, able to communicate in English or Yoruba, and willing to provide informed consent (and assent where applicable) to participate in the study (28). Recruitment methods included outreach through community organizations, healthcare providers and facilities, social media platforms (e.g., Facebook and Instagram), online forums, and in-person announcements and flyer promotions at secondary/high schools, universities, and community centers.

Data collection

The research team consisted of two investigators trained in semi-structured qualitative interviewing techniques and culturally sensitive research practices. This training ensured the collection of context-specific data while maintaining reflexivity (29). Participants were purposefully selected to capture diverse perspectives, ensuring that findings represented various sociocultural contexts (28). All interviews were conducted privately and in a culturally appropriate manner, fostering an environment conducive to open dialogue (25). Interviews were conducted using a semi-structured guide informed by the PEN-3 model. The semi-structured interview guide was developed with a shared core set of questions to explore participants' general knowledge and perceptions of cervical cancer, HPV prevention, cultural beliefs, social influences, facilitators and barriers, and preferences, which were asked across both groups. For instance, participant perceptions of family influence on decision-making, as well as discussions of barriers to and access to healthcare services for women and girls, alongside healthcare infrastructure, policy environments, and community resources, were assessed. The themes also addressed cultural influences, including family roles, community norms, and trust in healthcare providers. In addition, age-specific questions were included to address topics more relevant to each group, such as HPV vaccination among younger participants and HPV self-collection among older women. Participants were asked, “What do you know about HPV and cervical cancer?” and “What would encourage or discourage you from taking the HPV vaccine [for girls] or using self-collection methods [for women]?”

This method enabled cross-group thematic analysis of shared constructs (e.g., knowledge, perceptions, family influences) and a targeted assessment of age-specific HPV prevention behaviors. Probing questions gained insights into participants’ perceptions, enablers, and barriers, aligning with PEN-3 constructs. Interviews lasted 45–60 min, were audio-recorded, and supplemented with field notes capturing nonverbal cues and context. Ethical steps included informed consent and confidentiality.

Ethical considerations

Written informed consent was obtained from all participants before the interviews, with parental consent obtained for minors aged 9 to 17. Participants' identities were anonymized to ensure confidentiality, and audio recordings were securely stored. Participation in the study was voluntary, with participants free to withdraw at any time. Data security was maintained by storing all information on password-protected and encrypted devices. Data collection adhered to the highest ethical standards and was approved by the Nigerian Institute of Medical Research (NIMR) Institutional Review Board. Informed consent was obtained from all participants, and confidentiality and voluntary participation were emphasized throughout the study. COREQ guidelines also informed our data analysis strategy, ensuring transparency and rigor in the coding and interpretation of qualitative data.

Data analysis

Thematic analysis was conducted using the PEN-3 cultural model. The analysis involved (1) verbatim transcription of audio recordings, (2) accuracy checks to maintain data integrity and capture the full nuance of participant responses, and (3) coding and categorization based on theoretical frameworks (30).

Initially, a deductive coding approach was applied, guided by the predefined domains and constructs of the PEN-3 model to establish the coding scheme. We categorized data using constructs from the PEN-3 framework, such as Perceptions, Enablers, and Nurturers, thereby identifying specific themes related to HPV vaccination and self-collection behaviors that represent family, community, and structural influences from the PEN-3 model, thus providing a comprehensive understanding of participants' experiences and perceptions. For instance, discussions on access barriers to healthcare services, as well as inadequate healthcare infrastructure, policy environments, and community resources, were categorized within the Enabler domain of the PEN-3. Moreover, responses regarding the family's influence on cancer-prevention decision-making were coded as Nurturers, underscoring the significance of social dynamics and support for health behaviors.

Two independent researchers who conducted the data coding and theme identification met regularly to discuss and resolve discrepancies in their interpretations. This process also involved detailed coding matrices, peer debriefing, and memos to improve credibility and minimize potential bias. Data collection continued until saturation was reached, when no new themes emerged from additional data, confirming that the dataset was sufficient to meet the study's objectives. Saturation was assessed separately within each age group to ensure adequate representation across participant categories and systematically tracked using our coding matrices.

Results

Sociodemographic characteristics

Participants included younger (aged 9–26, n = 28) and older (aged 30–65, n = 28) female individuals from diverse religious, ethnic, and occupational backgrounds. Most of the younger females were in the 20–24 age group (53.6%), followed by those aged 15–19 years (25.0%) and 25–26 years (14.3%). Among older women, the most represented age groups were 35–39 years (28.6%) and 30–34 years (17.9%). Christianity was the predominant religion among younger (82.1%) and older (64.3%) females, whereas most identified as Yoruba, both younger (50.0%) and older (53.6%) participants.

For educational level among young adults, 10.7% had a BSC, 35.7% held an HND, and 42.9% had an SSCE. Older women reported: 25.0% with a BSC, 14.3% with an HND, and 39.3% with SSCE certificates; 7.1% did not report their educational level. Most older participants were traders (67.9%), followed by civil servants (10.7%), retired individuals (7.1%), and unemployed individuals (7.1%). Young adults were primarily students, traders, or civil servants. See Table 1.

Table 1. Sociodemographic characteristics of younger (aged 9–26) and older female participants (aged 30–65) in the study population.

BSc, Bachelor of Science; HND, Higher National Diploma; SSCE, Senior Secondary Certificate Examination.

Participants' general knowledge, perceptions, and preferences

Significant themes emerged across age groups regarding cultural identity, familial influences, and health-seeking behaviors related to HPV, cervical cancer, HPV vaccinations, and self-collection.

Cultural identity domain

Person

The analysis of participant narratives across both age groups revealed significant differences in knowledge and intrapersonal characteristics regarding HPV, its prevention, and linkage to cervical cancer. Younger participants expressed limited awareness about HPV vaccines and their linkage to cervical cancer, with statements like, “I have never heard about it,” (20 years) and “This is like the first time I am hearing about it.” (22 years). This was contrasted by a few individuals who displayed some understanding, recognizing HPV as a women's health issue. One participant demonstrated some knowledge by stating, “A cancer caused by a virus, it affects the cervix of a woman” (25 years). Another responded: “Yes, I have. It's just like HIV. It is being contracted through sex and through the blood” (24 years). See Table 2.

Table 2. Other relevant quotes categorized by PEN-3 cultural model among younger females (9–26years) regarding HPV vaccinations.

Similarly, many in this older group expressed limited knowledge about HPV, often stating, “I don’t know anything about cervical cancer.” Another explained, “It is cancer that occurs in the women in their private parts,” (37 years), with one statement reflecting a lack of urgency regarding HPV vaccination for their child: “I haven’t thought about getting my daughter vaccinated against HPV.” (56 years). A few participants who were health professionals demonstrated accurate understanding of cervical cancer and HPV: “It's a growth in the cervix area that can lead to carcinoma of the cervix.” Additionally, some older participants demonstrated confidence and self-efficacy in managing their health needs independently. For instance, one participant (39 years old) stated, “I can do it myself as long as I am taught,” reflecting a level of self-efficacy regarding using the HPV self-collection kit for screening. Conversely, others expressed hesitation by admitting: “I don’t think I can do it; I’d rather go to the hospital.” (43 years). See Table 3.

Table 3. Other relevant quotes categorized by PEN-3 cultural model among women (30–65 years) regarding HPV self-collection.

Extended family

The family's influence was a key factor in health-seeking behavior in both age groups, with male partners and family members identified as either facilitators or barriers. Caregivers of younger participants highlighted the role of family influences, stating, “…. you know I have to ask from the father of my daughter…” (65 years) and “For Nigerian culture, the father is the owner of the child” (56 years), underscoring the importance of supportive family structures in health decision-making. Similarly, younger participants indicated that decisions about vaccinations heavily depended on their family's approval: “Yes, they will have to allow me, for me to take it,” reflected this reliance on extended family support (19 years). See Tables 2, 3.

Among older participants, one (47 years) stated, “Men can encourage us, like reminding you and all that,” in contrast, another (43 years) noted, “If my husband says no, then I can’t go.” Some participants reported that family opinions would not ultimately prevent them from seeking preventive services: “It is necessary so I’ll make him understand… I will lecture him on why it is important.” (35 years). See Table 3.

Neighborhood

Both age groups preferred to access healthcare in familiar, nearby, and trusted local settings. Younger participants articulated a desire for vaccinations at recognizable healthcare facilities, such as local health centers: “I would prefer to get it from my hospital. I would least prefer an outreach like this,” and “I will still go to a health centre because I can trust them”. See Table 2.

Participants of older age echoed this sentiment, emphasizing the importance of local health facilities for accessibility, as indicated by remarks like, “I would prefer it at the pharmacy because it is nearby.” See Table 3.

Relationships and expectations

Perceptions

Among the younger participants, some questioned the necessity of the HPV vaccine when there are no symptoms: “If I am not having any symptoms, why will I just vaccinate myself?” (24 years). Some participants voiced concerns regarding vaccine safety, specifically fears about vaccine side effects, quality, and authenticity within the Nigerian health system: “You know Nigeria and expired vaccine, I don’t really trust Nigeria” (24 years). Regarding vaccines, another (43 years) also expressed: “I don’t know if it has after-effects, and that worries me.” Misinformation about the vaccines was shared: “Since it is the cervix, the vaccine may prevent me from having children.” (20 years). Despite a general low level of knowledge, some Participants perceived cervical cancer as serious and severe: “I just know it is deadly and it kills when it is not being detected early” (24 years). See Table 2.

Among older participants, opinions on HPV self-collection for cervical cancer screening received varied responses. One participant (39 years) expressed strong support, stating, “That's like the best idea ever, and I am going to take that approach. I will be willing to do that. I will just take the sample and take it to the hospital or the lab.” In contrast, another (57 years) preferred clinician-collected samples, noting, “It's also a good idea, but I prefer it to be taken by a professional rather than me taking it myself because they know better.” Misinformation and stigma were identified as barriers to health-seeking behaviors. Regarding misinformation, one (56 years) explained, “People may think it's checking for infection from sex,” and “They said maybe somebody put it on the chair… It's a curse.” (43 years). Another suggests that the self-collection samples might be used for nefarious purposes: “They may use it (samples) for ritual… people are afraid.” Stigma towards reproductive health was demonstrated by statements such as, “Women don’t want to talk about things that affect the private part,” and “Some people think it's an abomination.” Demonstrating reliance on spiritual protection and reduced perceived susceptibility to cervical cancer, one participant stated: “I am not praying to get that kind of sickness… the sickness will not know me.” See Table 3.

Enablers

Several factors that enable health-seeking behaviors across age groups were identified. Younger participants highlighted the importance of trusted endorsements from health authorities as key motivators for getting vaccinated. Some younger participants expressed concerns about the cost of vaccines and potential side effects, noting a narrow affordability range (₦3,500–₦5,000 per dose). One participant stated: “Cost, if it's too expensive, then I can’t.” (22 years). Younger participants preferred trusted health facilities such as private hospitals and government-recognized centers. School clinics were perceived as inadequate, whereas mobile outreach services were more widely accepted when affiliated with reputable health institutions. See Table 2.

Affordability and accessibility were especially important for older women when considering HPV self-collection or screening. Many indicated they were willing to pay small amounts: “I want it to be free… but maybe 500,” and adding, “If it's free, I’ll take my daughter for the vaccine, but I can only pay maybe 200 naira per dose” (56 years). While low costs were preferred, some participants were willing to pay more—typically 500–1,000 naira, and in a few cases up to 10,000 naira—depending on perceived importance and financial capacity.

Older participants also demonstrated a strong preference for proximity and formal healthcare settings. One participant (43 years) remarked, “I prefer the health center because I am sure what I am getting will be the right thing.” Another (56 years) added, “Pharmacies are closer to me, so I would go there for it,” with another citing, “They should make it closer to the market.” (65 years). Trust in the service provider was a recurring theme, with a participant (47 years) noting, “I trust the hospital because you need to be sure it's not expired or anything.” Some participants expressed preference for hospitals over pharmacies: “I prefer to get it from the hospital. I don’t know about these pharmacy people; they can just give you anything.” (62 years). See Table 3.

Nurturers

The influence of nurturers, particularly family members, emerged as a key factor shaping health decisions across age groups. Younger participants highlighted parental involvement, with one noting, “Permission from my parents. If they agree, it makes it easier and maybe they will help to pay if it's too expensive too,” (20 years) “My parents need to decide for me,” (18 years) and “Only if my mummy allows me,” (18 years) reflecting the impact of family engagement on health choices. Some were more skeptical of the positive influence of parents, likely due to limited parental awareness. One noted, “They will not do anything about it; I will be the one telling them about it,” (22 years), while an older adult stated, “Since she's a virgin, there's no need for it… it's now I know it's compulsory,” illustrating how minimal parental support may hinder HPV vaccination decisions. See Table 2.

Among older participants, mothers were sometimes identified as the primary caregivers and central decision-makers in health-related matters, as illustrated by one (45 years) who stated, “No, it's the mother. Because it's the mother who has time.” Another added: “Women should be more involved… it is our body.” (57 years). See Table 3.

Cultural empowerment

Positive

Participants exhibited positive attitudes toward health-seeking behaviors and prevention strategies: “Now that I know a little bit more about it, I want to get it” (24 years). Older participants, in particular, emphasized community responsibility, as illustrated by one remark, “I’m not sure how many of the men know about it. They need to be educated, and they need to encourage women to go for it.” (47 years). Several women noted that the HPV self-collection was preferred due to the reduced discomfort of undergoing a pelvic examination by a healthcare provider: “Most women will prefer it because of the privacy,” and “Some women are shy… they don’t allow anyone to see their privacy.” See Tables 2, 3.

Existential

Existential beliefs rooted in cultural and religious contexts emerged, shaping cervical cancer prevention behavior. For some participants, spiritual teachings and proverbs reinforced the importance of preventive care. As one explained (32 years), “Prevention is better than cure, as the adage says, so I should prevent with the vaccine.” Cultural norms emphasizing interdependence within families also influenced decision-making. Discussing HPV self-collection, one participant (47 years) noted, “If men know what is going on, they will tell their wives to go. The women can tell their husbands.” However, cultural beliefs and misconceptions also created barriers to health-seeking behaviors. One participant (47 years) shared, “I heard a woman sat on a chair with a charm and started bleeding…,” illustrating how myths and supernatural explanations can shape perceptions of cervical cancer. Stigma further complicated screening uptake, with another participant noting, “People may think it's checking for infection from sex.” (56 years)

At the same time, many older participants expressed strong trust in formal health systems, as reflected in remarks such as “ I will verify from the doctor,” indicating societal trust in medical professionals. This cultural complexity suggests that public health messaging must navigate and respect these deep-rooted belief systems to be truly effective. See Tables 2, 3.

Negative

Negative perceptions influenced by misinformation and stigma were common among both age groups. Younger participants expressed concerns driven by rumors, with one stating, “Hearing negative rumors will prevent me from taking the vaccine.” (22 years) Older participants also recognized ongoing misconceptions, including the belief that cervical cancer is “… about toilet infection” (60 years), reflecting culturally rooted stigmas that hinder preventive care. See Tables 2, 3.

Discussion

The HPV vaccine effectively reduces cervical cancer risk, and HPV self-sampling facilitates early detection and treatment of precancerous lesions, preventing progression to invasive disease (31). However, few studies have used theoretical frameworks to examine the cultural, social, and contextual factors influencing HPV vaccination and self-sampling uptake among girls and women in African settings. Applying the PEN-3 Cultural Model, we examined how cultural identity, family dynamics, healthcare preferences, and socio-economic factors shape health-seeking behaviors and influence women's autonomy in making informed health decisions. This qualitative study examined cultural, contextual, facilitator, and preference factors related to HPV vaccination and HPV self-collection among Nigerian girls and women. Our findings provide insights into the positive enablers that encourage HPV vaccine uptake and self-collection, as well as the negative barriers that hinder participation in preventive health services. Our findings revealed significant variations in knowledge about HPV and cervical cancer across age groups. Many younger participants had never heard of HPV, while older participants demonstrated a mix of understanding and misconceptions. While some older women were aware that HPV causes cervical cancer, many lacked a comprehensive understanding of the virus and its implications. This aligns with previous studies indicating that low HPV awareness is a significant barrier to HPV vaccination and screening in sub-Saharan Africa (27). Research suggests educational interventions tailored to specific demographic groups are crucial to improving HPV-related knowledge (32).

Family influence was another central theme frequently mentioned. Younger participants often reported that parental approval was required before they could receive the HPV vaccine, whereas older women emphasized their husbands' role in health decision-making. These findings underscore the influence of family dynamics on girls' and women's health decisions, consistent with prior research on reproductive behaviors in patriarchal societies (32). These findings reflect broader social structures, economic factors, and cultural norms that govern girls' and women's health behaviors in patriarchal contexts and are consistent with prior research on reproductive decision-making (33). Overall, our findings stress the critical role of family dynamics, social organization, and cultural context in shaping HPV prevention behaviors among Nigerian populations. Persistently low awareness of HPV and cervical cancer highlights the urgent need for comprehensive, age-appropriate educational campaigns targeting both adolescents and adults. Notably, the prominent role of parents and spouses suggests that future HPV prevention efforts should be community-based and family-inclusive, to ensure cohesive, informed, and sustained uptake of vaccination and self-collection services.

Participants reported multiple barriers to HPV vaccination and self-collection, including financial constraints, misinformation, stigma, and concerns about vaccine side effects. Older participants, in particular, expressed fear of social stigma, consistent with prior research showing that HPV stigmatization as a sexually transmitted infection discourages vaccine uptake in conservative communities. Financial barriers also emerged as a prominent theme. At the same time, some participants were willing to pay a reasonable amount for the vaccine, their willingness to pay varied widely, ranging from 100 naira to 10,000 naira, with most responses falling between 2,000 and 5,000 naira. The findings reinforce prior research indicating that cost remains a significant determinant of vaccine acceptance in LMICs (34).

Trust in healthcare providers and formal institutions emerged as a central determinant of HPV vaccine acceptance and self-collection participation. Participants expressed a strong preference for receiving services in trusted settings such as hospitals, pharmacies, and schools, underscoring the importance of integrating HPV prevention into routine healthcare and educational settings. Some younger participants favored school-based vaccinations, citing convenience and professional oversight, while older participants perceived pharmacies as more accessible. Together, these preferences underline the critical role of trusted healthcare infrastructure in improving vaccination and screening uptake across age groups. These findings are consistent with global evidence indicating that trust in the health system and service convenience are key drivers of vaccine uptake (34). Expanding HPV vaccination delivery through schools and community pharmacies may therefore enhance access and coverage for HPV prevention efforts.

Furthermore, endorsements from religious leaders, health ministries, and high-profile public figures could enhance the perceived legitimacy of HPV vaccination, suggesting that engaging influential community stakeholders can further promote uptake (25). Given participants' high level of trust in healthcare providers, equipping clinicians and pharmacists to actively recommend HPV vaccination and self-collection may enhance confidence in these preventive interventions (35). It is beneficial to promote positive cultural values, such as emphasizing cancer control rather than HPV (STI) prevention messaging, and highlighting the maternal role in health decision-making. Addressing misinformation and stigma through targeted, socio-culturally appropriate educational initiatives, particularly within schools, faith-based institutions, and media platforms, can help dispel misconceptions about HPV, normalize cervical cancer prevention, and improve understanding of female reproductive anatomy, thereby supporting informed decision-making and increasing acceptability of HPV self-collection (27, 34).

Financial concerns were a significant deterrent, emphasizing the need for government-subsidized or donor-supported HPV vaccination programs. As a result, low-cost cervical screening programs within Nigeria's National Health Insurance Scheme, along with donor-funded efforts, could improve affordability and uptake (34). Additionally, mixed reactions to self-collection suggest that while some women appreciate its convenience and privacy, others still prefer professional handling. This indicates the need for training and awareness campaigns to improve confidence in self-collection methods (35). Furthermore, expanding vaccination and screening programs to trusted community venues like schools, pharmacies, and local health facilities would be consistent with participants' preferences for accessibility and professional oversight (27, 32).

Privacy and convenience are key preferences for self-collection; therefore, emphasizing dignity and privacy rather than pain and exposure could improve adoption (7). Engaging men as community gatekeepers, providing clear instructions, trusted distribution points, visual aids, and socio-culturally appropriate demonstrations, disseminated using community channels (markets, churches, mosques, radio) can enhance vaccine confidence and competence in HPV self-collection, particularly among women with low health literacy (35). Overall, multi-level interventions that include cost-cutting techniques, community-based education, provider-driven recommendations, and improved service accessibility are critical for increasing HPV vaccination and self-collection rates in Nigeria (18). Future strategies should emphasize culturally relevant messaging, integrating services into routine healthcare, and involving trusted community leaders in long-term cervical cancer prevention programs (25, 27).

Study limitations

This study has several limitations. First, self-reported data may be subject to social desirability bias, as participants might have provided responses they perceived as favorable. Second, the sample was limited to Lagos State, which may not fully capture Nigeria's diverse cultural and socio-economic landscape. Third, girls in the “younger” group (9–26 years) were largely represented by those aged 20–24 due to consent and logistical issues with minors, leading to underrepresentation of younger adolescents. Moreover, while we used purposive sampling to ensure representation, the findings may not be generalizable to all Nigerian women. Future research should incorporate larger, more diverse samples across multiple states and regions, and should also capture the perspectives of younger adolescents to better inform HPV vaccination strategies.

Conclusion

Overall, our findings emphasize the interaction of multiple levels of factors, including individual, relational, sociocultural, and structural influences that shape HPV prevention behaviors, consistent with the PEN-3 domains. Addressing structural, social, and cultural factors is crucial for increasing HPV vaccine coverage and promoting equitable cervical cancer prevention in Nigeria.

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Supplementary material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fcacs.2026.1790326/full#supplementary-material

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Footnotes

Edited by: Edvīns Miklaševičs, Riga Stradiņš University, Latvia

Reviewed by: Amina Abdulkarim, Solina Centre for International Development and Research (SCIDaR), Nigeria

Kurnia Wijayanti, Indonesia University of Education, Indonesia