Background:
Cervical cancer remains a major public health concern in Tamil Nadu, India, where it is the second most common cancer among women. Although largely preventable through screening and human papillomavirus (HPV) vaccination, challenges remain due to limited awareness, delayed diagnosis, and inadequate access to preventive services. In alignment with the WHO’s cervical cancer elimination target by 2030, Tamil Nadu has demonstrated strong political commitment by announcing the introduction of HPV vaccination for 14-year-old girls. However, effective implementation requires addressing challenges related to policy clarity, multisectoral coordination, and community acceptance. 

Objective:
1. To identify key facilitators and barriers to HPV vaccine implementation.
2. To co-create evidence-based, actionable recommendations to support effective statewide HPV vaccine implementation.

Methods:
Thirty-three in-depth interviews were conducted with stakeholders across macro (14), meso (13), and micro (6) levels in the Viluppuram and Chennai districts. Stakeholders were identified in consultation with officials from the Department of Health and Family Welfare, using purposive sampling with snowball technique. Data were thematically analyzed using the Consolidated Framework for Implementation Research (CFIR) to identify determinants influencing HPV vaccine implementation. Findings informed a multisectoral co-creation meeting involving policymakers and state and district officials from the health, education, and social welfare sectors, professional bodies, and technical partners. Recommendations emerged from the study were prioritized using a dot-voting technique, followed by feasibility–impact matrix analysis to identify high-priority, actionable strategies.

Results:
Barriers to HPV vaccine implementation included: concerns about adverse events and perceived complexity (Intervention Characteristics); misinformation, stigma, gender norms, and public mistrust (Outer Setting); infrastructure gaps, workload pressures, and weak intersectoral coordination (Inner Setting); provider knowledge gaps and hesitancy (Individual Characteristics); and challenges related to enrolment, engagement, and communication (Process). Key facilitators included strong immunization and data systems, government commitment, budgetary support and technical partnerships (Inner Setting); trusted frontline workers, peer champions, and community receptiveness (Outer Setting); scientific endorsement and positive framing of HPV vaccination (Intervention Characteristics); provider capacity and professional body involvement (Individual Characteristics); and phased roll-out planning supported by regular reviews (Process).
Through the co-creation process, stakeholders emphasized framing HPV vaccination as a cervical cancer prevention intervention, strong government leadership to counter misinformation, locally tailored multi-channel communication strategies, transparent consent processes, and close operational coordination between health and education sectors, with schools serving as trusted delivery platforms. Among the 34 recommendations identified from the study, ten high-feasibility, high-impact recommendations were prioritized, emphasizing intensive community engagement, school-based vaccination of 9–14-year-old girls, integration with existing school health and immunization platforms, strengthened intersectoral coordination, provider capacity building, structured pre-rollout planning, uniform guidelines, and inclusion of HPV vaccination within routine immunization using trusted frontline workers as primary messengers (Figure).

Conclusion:
Successful HPV vaccine implementation in Tamil Nadu requires addressing multilevel implementation barriers while leveraging existing system strengths. A stakeholder-driven co-creation process generated contextually relevant, feasible, and high-impact strategies focusing on community trust-building, intersectoral collaboration, health-system integration, and provider readiness. Implementing these recommendations can strengthen program delivery, improve vaccine acceptance and coverage, and accelerate progress toward cervical cancer elimination in line with national and global goals.
 

Prioritized Recommendations identified by stakeholders by Feasibility Impact analysis