Boosting community engagement: Leveraging the ward health system approach for enhanced HPV vaccination acceptance in Nigeria.

3.1 Study design

To investigate the effectiveness of leveraging the Ward Health System (WHS) approach for enhancing HPV vaccination acceptance in Nigeria, a mixed-methods approach was employed (Hsieh and Shannon, 2005; Dawadi et al., 2021; Guetterman et al., 2021). This approach integrated quantitative surveys with qualitative interviews to provide a comprehensive understanding of the factors influencing HPV vaccination uptake.

3.2 Sampling and data collection

The study sampled phase one states across various regions of Nigeria, focusing on areas with varying levels of HPV vaccination uptake. This stratified sampling ensured a representative distribution of data reflecting diverse socio-cultural contexts.

3.3 Data synthesis and analysis

A variety of relevant keywords (e.g., Boosting Community Engagement, Leveraging Ward Health System Approach, Enhanced HPV Vaccination, HPV Vaccination Acceptance) were employed to gather pertinent material on the topic. This comprehensive search strategy utilized scholarly search engines such as EBSCO Discovery Service (EDS), Google Scholar, Google Books, Microsoft Academic, PubMed, ProQuest Dissertations & Theses, CINAHL EBSCO Host, Web of Knowledge, Mendeley, SSRN, ResearchGate, and Worldwide Science. Additionally, individual blogs, online newspapers, and internet reports were reviewed to ensure a broad scope of information.

3.4 Content analysis

A methodical approach to content analysis was employed to examine the collected texts. Particular emphasis was placed on the subjective interpretation of the data by the reader, aiming to identify and track emerging trends in community engagement related to HPV vaccination.

3.5 Discourse analysis

Discourse analysis was utilized to study the linguistic features of scholarly research publications, including tone, phonology, syntax, style, and organization. This method allowed for the deconstruction of texts to reveal implicit or hidden content through critical thinking and reasoning. By doing so, trustworthy data aligning with the study’s goals were extracted, providing a robust foundation for subsequent analysis. Thus, this study employed a mixed-methods approach to leverage the WHS for boosting community engagement and enhancing HPV vaccination acceptance in Nigeria. By combining quantitative surveys with qualitative interviews and employing rigorous data analysis techniques, the study aimed to uncover actionable insights that can inform public health strategies and improve vaccination coverage.

4.1 The human papilloma virus, the HPV vaccine, and UHC

The most prevalent virus that affects the reproductive system is the human papillomavirus (HPV), often described as an “equal opportunity” pathogen because it affects both sexes (De Vuyst et al., 2013). Men and women can develop a variety of illnesses from HPV, including precancerous lesions that have the potential to develop into cancer (Ginsburg et al., 2017). Persistent HPV infections can cause serious illness, even though the majority of infections are asymptomatic and clear up on their own. Women who have a history of oncogenic HPV infections may develop cervical intraepithelial neoplasia (CIN), which can develop into invasive cervical cancer if left untreated (see Figure 1A, B and C above). An observational research for women up to 30 years old utilizing data from the population-based cancer registry showed that the introduction of a national bivalent (Cervarix) HPV immunization program resulted in women who had the vaccination between the ages of 12 and 13 almost completely free of cervical cance. This demonstrates that vaccination against oncogenic HPV types is a critical step towards reducing the prevalence, morbidity, and mortality associated with cervical cancer (Denny et al., 2006; Denny and Anorlu, 2012; De Vuyst et al., 2013; Akinde et al., 2015; Balogun and Omotade, 2018; Waheed et al., 2022). Among Nigerian women aged 15 to 44, cervical cancer is the second most common cause of cancer-related deaths and the third most common type of cancer overall. 2020 saw 12,000 new cases of cervical cancer and 8,000 fatal cases nationwide (see Figure 1A above). Thus, primary healthcare plays a significant role in Nigeria’s HPV vaccination strategy, aligning with the Universal Health Coverage (UHC) mandate (Okechukwu et al., 2024; Oweibia et al., 2024; Abaya et al., 2024; Christopher et al., 2024a). A five-day mass vaccination campaign in schools and communities marked the inaugural rollout in 16 states and they include: Abia, Bauchi, Adamawa, Akwa Ibom, Bayelsa, Benue, Enugu, Jigawa, Taraba, Federal Capital Territory (FCT), Kano, Kebbi, Lagos, Nasarawa, Ogun, Osun are prioritized for phase 1 introduction in September 2023 with their achievement (see Figure 2 below). Following this, the vaccine are incorporated into routine immunization schedules within health facilities.

Figure 2. NPHCDA daily call in data.

Source: NPHCDA.

The second phase of the vaccination rollout is set to start in May 2024 in 21 states which include (Anambra, Borno, Cross-River, Delta, Ebonyi, Edo, Ekiti, Gombe, Imo, Kwara, Kogi, Ondo, Rivers, Oyo, Sokoto, Kaduna, Katsina, Niger, Yobe, Plateau and Zamfara). This strategy ensures that in all 4,163 wards in the 16 states targeted in the first phase, vaccination sites and mobile units are established to reach remote communities. Primary healthcare centers will be pivotal in sustainably providing HPV vaccination services, with plans to scale up across about 10,000 wards in Nigeria. Hence, Ward Development Committees (WDCs) are essential in coordinating the community’s full participation, ensuring the process is affordable and sustainable at every development stage in the spirit of self-reliance and self-determination. The WHO’s statement on UHC for the 2018 World Health Day defines UHC as ensuring “every individual and community has access to the healthcare they require without facing financial hardship”. UHC guarantees that patients have access to treatments that target the leading causes of illness and death, these services are of high quality to improve health outcomes (Raimi et al., 2017; Raimi et al., 2018; Olalekan et al., 2018; Olalekan et al., 2018b; Raimi et al., 2019a, b, f, g, h; Olalekan et al., 2019a; Omidiji and Raimi, 2019; Gift and Olalekan, 2020; Gift et al., 2020; Raimi et al., 2020b; Adedoyin et al., 2020; Olalekan et al., 2020a, b, c; Morufu et al., 2021c; Raimi et al., 2022a, b). The WHO further explains that UHC is not only about providing a minimum package of health services but also about progressively expanding coverage and financial protection as more resources become available. UHC encompasses individual medical treatments and population-wide services such as public health campaigns, for example, adding fluoride to water (Morufu and Clinton, 2017; Raimi and Sabinus, 2017; Olalekan et al., 2018; Suleiman et al., 2019; Raimi, 2019; Afolabi and Morufu, 2021; Raimi et al., 2021e; Morufu et al., 2021c, d, e; Afolabi and Raimi, 2021; Raimi et al., 2022c, d, e; Ifeanyichukwu et al., 2022; Olalekan et al., 2022; Raimi and Sawyerr, 2022; Raimi et al., 2023) or controlling mosquito breeding grounds (Raimi et al., 2017; Raimi et al., 2018b; Morufu et al., 2021f; Awogbami et al., 2024; Akayinaboderi et al., 2024; Clinton-Ezekwe et al., 2024). These guiding principles, among others, form the core objectives of UHC. Given this comprehensive framework, the integration of HPV vaccination into Nigeria’s health system underscores the importance of primary healthcare and community involvement. By leveraging the WHS and the managerial support of WDCs, Nigeria aims to build trust, reduce vaccine hesitancy (Cunningham et al., 2014; Gallagher et al., 2017), and achieve high vaccination rates (Nkwonta et al., 2020). This collaborative approach aligns with UHC principles and is essential for improving public health outcomes and ensuring sustainable health gains relative to investments (Omidiji and Raimi, 2019; Raimi et al., 2019g, h; Raimi et al., 2020b; Adedoyin et al., 2020; Olalekan et al., 2020a, c).

4.2 Significance and benefits of fast-tracking demand and acceptance of HPVV

Universal Health Coverage (UHC) is essential for providing equitable, high-quality, and universally accessible healthcare for all Nigerians without causing financial hardship. It emphasizes the critical role of a healthy population in driving sustainable, equitable, and inclusive economic growth and national development (Tuebi et al., 2021; Morufu et al., 2021a, c; Christopher et al., 2024a; Mordecai et al., 2024; Oweibia et al., 2024). As a cornerstone of the UHC mandate, primary health care is tailored to reflect the economic conditions, sociocultural, and political characteristics of Nigeria and its communities. It is grounded in the use of pertinent findings from public health, biological, and social sciences experiences (Raimi et al., 2022; Dine et al., 2023; Uchenna et al., 2024), addressing the main health problems in the community through promotive, preventive, curative, and rehabilitative services (Barbara et al., 2012; Christopher et al., 2024a, b). The HPV vaccine is a vital component of the World Health Organization’s (WHO) strategy to eliminate cervical cancer as a public health issue by 2030. This strategy aims to ensure that 90% of girls receive the complete HPV vaccine series before they turn 15. Nigeria’s plan to integrate the HPV vaccine into its routine immunization schedule targets the primary cause of cervical cancer. However, successful integration relies on overcoming vaccine hesitancy and fostering communal trust (DiAngi et al., 2011; Troiano and Nardi, 2021; Raimi et al., 2021a, b).

In a context where people’s perceptions and reactions to public health interventions significantly influence their effectiveness, social listening has become a crucial tool for understanding attitudes and perceptions of these interventions through community engagement cycle for HPV vaccination (see Figure 3 below). This approach is particularly relevant for the introduction of the HPV vaccine in Nigeria, which represents a monumental stride towards protecting Nigerian girls from cervical cancer (Restivo et al., 2018; Icardi et al., 2020). The vaccination not only prevents a severe disease but also promises a future where young Nigerian women can thrive, unburdened by the specter of this significant health concern. To achieve these goals, Nigeria must leverage its primary healthcare system, which evolves based on the country’s unique conditions and characteristics. The HPV vaccine will be introduced in phases, starting with a five-day mass immunization campaign in communities and schools throughout 16 states as well as the Federal Capital Territory. The vaccine will thereafter be incorporated into regular immunization schedules in healthcare facilities. The second phase is scheduled to start in May 2024 and span 21 more states, with vaccination sites and mobile units established to reach remote communities. Primary healthcare centers will play a pivotal role in this sustainable model, aiming for a full-scale rollout across about 10,000 wards in Nigeria. Central to this strategy are the Ward Development Committees (WDCs), which coordinate community participation and ensure the process is affordable and sustainable. The WHO’s definition of UHC emphasizes that UHC “enables everyone to access services addressing the most significant causes of disease and death, and that all people and communities receive the health services they need without suffering financial hardship”, ensuring quality services that improve health outcomes.” UHC is not only about providing a minimum package of health services but also about progressively expanding coverage and financial protection as resources grow. It includes both individual medical treatments and population-wide services, such as public health campaigns like water fluoridation or mosquito control (Raimi et al., 2017; Raimi et al., 2018; Olalekan et al., 2018; Raimi et al., 2020; Gift and Olalekan, 2020; Samson et al., 2020; Olalekan et al., 2020a, b, c; Raimi et al., 2021b, c; Olalekan et al., 2022; Raimi et al., 2023; Awogbami et al., 2024; Clinton-Ezekwe et al., 2024). By aligning with these UHC principles, Nigeria’s HPV vaccination initiative aims to build trust, reduce vaccine hesitancy, and achieve high vaccination rates (Holman et al., 2014; Dror et al., 2020; Troiano and Nardi, 2021; Soares et al., 2021). This comprehensive approach involves collaboration with diverse health organizations, community leaders, and members, fostering a sense of ownership and commitment. Ultimately, leveraging a robust primary healthcare system and the managerial support of WDCs is crucial for achieving sustainable health gains and improving public health outcomes in Nigeria (Demarteau et al., 2014; Akinde et al., 2015; Swanson et al., 2018).

Figure 3. Community Engagement Cycle for HPV Vaccination.

4.3 Current state of demand and acceptance of HPVV in Nigeria

A social listening study revealed varied attitudes towards the introduction of the HPV vaccine in Nigeria, with a significant portion of comments indicating vaccine hesitancy (Agyei-Baffour et al., 2020). Many individuals expressed suspicions about hidden motives and intentions behind the vaccine’s introduction. Some comments showed outright refusal to accept any vaccine, including the HPV vaccine. This resistance was compounded by varying levels of knowledge about HPV and its vaccine, and a basic understanding of HPV’s association with cervical cancer (Umeh et al., 2016). Instances of misinformation were prevalent, with individuals questioning the vaccine’s safety and effectiveness, linking it to conspiracy theories, and believing that cancer prevention could be achieved solely through lifestyle choices (Abdulraheem et al., 2018; Funmilayo et al., 2019; Raimi et al., 2019c; Azi et al., 2024; Austin-Asomeji et al., 2024). These misconceptions significantly influence the demand and acceptance of the HPV vaccine (Fagbule et al., 2020). In light of this backdrop, it is evident that exploring effective systemic strategies to fast-track the demand and acceptance of the HPV vaccine in Nigeria is crucial. To achieve this, Nigeria must leverage the most far-reaching components of its health system to build trust, reduce hesitancy, increase demand, and maintain compliance. This approach aims to ensure the sustainability of health outcome gains relative to investments. Leveraging primary healthcare and community engagement through Ward Development Committees (WDCs) is essential. WDCs play a critical role in coordinating community participation, fostering a sense of ownership, and ensuring the process is affordable and sustainable. Engaging diverse health organizations, community leaders, and members can bolster trust and participation, promoting a shared understanding of the importance of HPV vaccination in preventing cervical cancer (Coleman et al., 2011; Umeh et al., 2016). Aligning these efforts with the principles of Universal Health Coverage (UHC), which emphasizes accessible, high-quality health services without financial hardship, is key. By implementing comprehensive community-based strategies and addressing misinformation through effective communication and education, Nigeria can drive up demand for the HPV vaccine, overcome hesitancy, and achieve high vaccination rates. This collaborative and systemic approach is vital for improving public health outcomes and ensuring the sustainable success of the HPV vaccination program in Nigeria (Goldie et al., 2008; Demarteau et al., 2014; Ver et al., 2021).

5.1 Role and functions of ward development committees in Nigeria

Managerial support for the Ward Health System (WHS) in Nigeria is fundamentally community-based, comprising two key committees: Ward Development Committees (WDCs) at the ward level and Village Development Committees (VDCs). The chairmen of all VDCs within a ward join other eligible community members to form the WDC. It is mandated that only one WDC exists in each political ward to oversee health and development activities, ensuring a streamlined and effective management structure (see Figure 4 below).

Figure 4. WDC Linkage to the Ward Political Structure.

The Ward Health System (WHS) is designed to enhance the effectiveness of healthcare services by emphasizing community-based approaches. It focuses on building local capacity at all levels, promoting the active participation of community members to increase ownership and sustainability, motivating local resource mobilization, and ensuring the optimal use of funds. Additionally, the WHS facilitates information sharing with other stakeholders and promotes local health initiatives. The primary goals and objectives of the WHS include:

By focusing on these objectives, the WHS aims to create a robust and responsive primary healthcare system that meets the needs of all Nigerians, particularly those at the grassroots level. The WHS not only aims to improve health outcomes but also to build a sense of community ownership and responsibility, ensuring that health interventions are sustainable and impactful (Chen and Stanton, 2012; Alford and Durand, 2018). The Ward Development Committees (WDCs) and Village Development Committees (VDCs) play a crucial role in this system. They ensure that health initiatives are tailored to the specific needs of each community, fostering a bottom-up approach to health service delivery. This structure allows for effective community mobilization and resource allocation, promoting a holistic approach to health and development (Bandura, 2004; Barbara et al., 2012; Bai and Batterham, 2015). Through the WHS, Nigeria seeks to align its health system with the principles of Universal Health Coverage (UHC), ensuring that all individuals have access to the health services they need without financial hardship. This comprehensive approach not only addresses immediate health needs but also contributes to long-term health and developmental goals, fostering a healthier, more resilient population (Christopher et al., 2024a, b).

5.2 Composition, structure, and responsibilities of ward development committees in Nigeria

The Ward Health System serves as a strategic social framework aimed at fostering community participation and enhancing access to primary healthcare services. Ward Development Committees play a pivotal role in this system, collaborating closely with health facility managers to ensure comprehensive community ownership and effective reporting of primary healthcare issues (Ward Development Committee, 2024). These committees are entrusted with a range of responsibilities, including but not limited to health promotion and community mobilization, maternal and newborn child health services, nutrition, and the control of both communicable and non-communicable diseases. They also play a vital role in sexual and reproductive health initiatives, ensuring that community members have access to essential services and information (Development Communication Network, 2017). One of the crucial functions of Ward Development Committees is to monitor newborns, particularly those delivered at home, and promptly report their status to health facility managers. This ensures that newborns receive timely follow-up care and immunizations as required, safeguarding their health and well-being (Ward Development Committee, 2024).

In line with principles of gender equity and inclusivity, the composition of Ward Development Committees is mandated to include at least 40% women, with one woman holding an executive post. This ensures diverse representation and empowers women to actively contribute to decision-making processes related to primary healthcare within their communities (Allen and West, 2016). By fostering collaboration between community members and healthcare professionals, the Ward Health System promotes a holistic approach to healthcare delivery. It not only enhances access to essential services but also empowers communities to take ownership of their health outcomes. Through effective community engagement and the proactive involvement of Ward Development Committees, Nigeria strives to build a resilient and responsive primary healthcare system that addresses the diverse needs of its population (Campbell and Cornish, 2015).

5.3 WDC responsibilities

The framework outlined below illustrates the Ward Development Committee’s theory of Change, emphasizing enhanced community participation and ownership, a cornerstone of the Ward Health System within the broader Nigerian healthcare landscape. In the execution of the Ward Minimum Health Care Package (WMHCP), the Ward Health System plays a pivotal role in mobilizing communities, facilitating defaulter tracing, and maintaining meticulous records of immunized children. Health workers stationed at the ward level collaborate closely with Ward Development Committees to implement routine immunization and ensure the accurate upkeep of Primary Healthcare Management Information System records (PHCMIS), contributing to the national health information system. Continuous monitoring and supervision are enforced at all levels through the Ward Health System, ensuring the effective delivery of healthcare services (see Figure 5 below).

Figure 5. WDC theory of change.

In nutrition programs, the support of Ward Development Committees is indispensable in devising strategies to encourage households to augment food production for consumption. This involves initiatives such as promoting home gardens and community farming, fostering self-sufficiency and food security within communities. Additionally, in the realm of health education, Ward Development Committees collaborate with health workers and educators at the ward/community level to conduct comprehensive school health education programs. These programs are strategically designed to reach children and employ advocacy methods tailored to garner support from community leaders, thus enhancing health literacy and promoting healthy behaviors from an early age (Baum and Fisher, 2014; Breton et al., 2019; Morufu et al., 2021). The Ward Minimum Health Care Package guidelines underscore the essential role of the Ward Health System in facilitating collaboration between Ward Development Committees and health workers in supervising various activities both within and outside health facilities. Moreover, community-led initiatives to establish additional health facilities receive support through Ward Development Committees, fostering a decentralized approach to healthcare provision (Ward Development Committee, 2024).

Furthermore, the Ward Health System is tasked with heightening awareness about the significance of safe water and sanitation practices through community mobilization efforts led by Ward Development Committees (Raimi et al., 2017; Olalekan et al., 2018; Raimi et al., 2018; Gift and Olalekan, 2020; Gift et al., 2020). By engaging communities in discussions about water and sanitation, the Ward Health System strives to promote health and hygiene practices that contribute to overall well-being (DeSalvo et al., 2011; WHO, 2017). In essence, the Ward Health System embodies a collaborative and community-driven approach to healthcare delivery, fostering a sense of ownership and empowerment within local communities. Through these concerted efforts, Nigeria endeavors to build a resilient healthcare system that addresses the diverse needs of its population while promoting health and well-being at the grassroots level (Allender et al., 2019; Oyeyemi et al., 2021, 2022).

5.4 Existing challenges and limitations of the ward health system model

The Ward Health System model operates within the broader Nigerian healthcare framework, benefiting from advancements and facing challenges in tandem. The effectiveness of healthcare services provided by Ward Development Committees directly correlates with the state of infrastructure, supplies, and staffing within healthcare facilities. Inadequacies in these areas can hinder the Ward Health System’s ability to meet the community’s healthcare needs, impeding efforts to promote health-seeking behavior through comprehensive community mobilization (Yahya, 2007; Blanco et al., 2019; Buckley and Sheehan, 2019). Moreover, the presence or absence of robust institutional coordinating mechanisms at lower levels can impact the sustainability of the gains achieved through active engagement of Ward Development Committees. Factors such as incentive structures, recognition schemes, and the establishment of effective networking platforms for grassroots collaboration play crucial roles in maintaining the functionality of Ward Development Committees. Neglecting these aspects can disrupt the workflow of WDCs and undermine their effectiveness in delivering healthcare services at the community level (Ward Development Committees, 2024). Therefore, the success of the Ward Health System model in contributing to the Nigerian healthcare system hinges on the meticulous implementation of relevant national ward health system frameworks and guidelines by stakeholders at the national, state, and local government levels. By prioritizing the establishment of supportive institutional structures and ensuring adherence to established protocols, stakeholders can maximize the impact of Ward Development Committees in improving healthcare access and outcomes across Nigeria. This concerted effort is essential for realizing the full potential of the Ward Health System model as a catalyst for positive change within the Nigerian healthcare landscape.

6.1 Gaps and opportunities for fast-tracking demand and acceptance of HPVV through the WHS

A study on social listening revealed a spectrum of attitudes towards the introduction of the HPV vaccine in Nigeria, with a notable portion expressing hesitancy. Many individuals expressed suspicions regarding hidden motives behind the vaccine’s introduction, while some outright refused vaccination, including the HPV vaccine. Varying levels of public knowledge about HPV and its association with cervical cancer influence the demand and acceptance of HPV vaccination. Instances of misinformation, questioning the vaccine’s safety and effectiveness, and associating it with conspiracy theories or believing that cancer prevention relies solely on lifestyle choices have been documented (Odukoya et al., 2013; Erhabor et al., 2014). In response, it’s imperative for Nigeria to explore systemic measures to expedite demand and acceptance of HPV vaccination. Leveraging the robust infrastructure of the ward health system becomes crucial for building trust, addressing hesitancy, and fostering demand while ensuring sustained compliance. Over time, the ward health system has demonstrated success in stimulating demand for health services through community sensitization, dialogue, and active participation in immunization campaigns (Oyeyemi and Ogunleye, 2013; Osaro and Charles, 2014; Osaro et al., 2020; Oyeyemi et al., 2021, 2022). The Ward Development Committees (WDCs) within the ward health system can play a pivotal role in overcoming hesitancy and misinformation surrounding the HPV vaccine. By engaging with communities, WDCs can dispel suspicions, address vaccine resistance, and bridge knowledge gaps regarding HPV and its vaccination. They can also rectify misinformation and promote understanding of the vaccine’s importance in cervical cancer prevention, thus enhancing vaccination acceptance (see Figure 6A and B below) (Denny and Anorlu, 2012; Markowitz et al., 2014; Oyeyemi et al., 2021, 2022).

Figure 6. A&B: Enhancing HPV Vaccination Acceptance in Nigeria.

To guide the implementation of the ward health system, the National Primary Health Care Development Agency has developed the Ward Minimum Health Care Package. This package outlines clear guidelines for maximizing the potential of WDCs in driving universal health coverage. It emphasizes training health workers and community members as health educators, establishing drug revolving schemes, and capacitating WDCs to handle emergencies and disasters (Raimi 2019; Raimi et al., 2021d). However, the effective implementation of these guidelines across Nigeria warrants scrutiny to identify barriers hindering their operational performance and impact within the healthcare system. Addressing these challenges is pivotal for Nigeria to harness the full potential of the ward health system in promoting demand and acceptance of HPV vaccination nationwide (Bosch et al., 2013; Falcaro et al., 2021).

6.2 Strategies to fast-track demand and acceptance of HPVV through the ward health system

Ward development committees can be leveraged to deliver the needful positive push for overcoming hesitancy indications around the introduction of the HPV vaccine in Nigeria. They can allay voiced suspicions of hidden motives and intentions behind its introduction in Nigeria and douse vaccine resistance where people express outright refusal to take any vaccine, including the HPV vaccine. If well engaged, WDCs can play an important role in bridging the gaps across the varying levels of knowledge among the public regarding HPV and the vaccine as wells as increase the spread of basic understanding of HPV’s association with cervical cancer and the importance of vaccination in cervical cancer. WDCs can also play a critical role in making right any instances of misinformation in their locales, where individuals question the HPV vaccine’s safety and effectiveness, and associate it with conspiracy theories as well as any though patterns indicating beliefs that cancer prevention can solely be achieved through lifestyle choices. These factors influence the subject of demand and acceptance of HPVV (Anorlu et al., 2010; Ahmed et al., 2013; Denny et al., 2014; Nguyen et al., 2020). Consequently, the ward health system can thus be pivotal to bridging gaps towards ensuring increased demand and acceptance of HPV vaccination in the country.

However, against delivering the foregoing: Currently, Nigeria cannot boast of fully operational ward development committees across all about 10,000 political wards in the nation, with many requiring reactivations. Several strategies have been geared at repositioning the ward health system with some reactivation efforts proposing and executing the following;

Reactivation trainings must feature the roles and responsibilities, structure and composition of the WDC, resource mobilization and management strategies as well as the accountability framework to improve the functionality, performance and reposition WDCs as a driving force in community participation in the health care service delivery process.

6.3 Significance of community engagement and participation in fast-tracking demand and acceptance of HPVV through the WHS

The overarching objective of universal health coverage aligns closely with the mandate of the Nigeria HPV vaccination strategy: to ensure equitable access to quality health services without imposing financial burdens. However, societal norms often impede individuals from accessing healthcare when needed, highlighting the critical importance of community engagement to overcome such barriers. By effectively mobilizing local actors deeply embedded within communities, progress can be made towards achieving health equity. For instance, in Bauchi state, efforts led by Ward Development Committees (WDCs) in collaboration with the National Union of Road Transport Workers have resulted in the establishment of a community-based emergency transport system (ETS). This initiative, operational round-the-clock and manned by volunteer drivers, provides pregnant women with accessible transportation to healthcare facilities. Thanks to the concerted efforts of WDCs, the number of pregnant women utilizing this service has steadily increased, demonstrating the impact of community-led interventions on improving healthcare access (Morufu et al., 2021; Oyeyemi et al., 2021, 2022; Raimi et al., 2021b; Kakwi et al., 2024; Elemuwa et al., 2024a). This innovative approach underscores the vital role of intentional community engagement in devising sustainable models for enhancing healthcare access, as facilitated by WDCs. Therefore, strengthening mechanisms for tailored community involvement and participation within the framework of the ward health system is both imperative and urgent. WDCs, uniquely positioned within their respective communities, possess invaluable insights into the intricacies influencing the demand and acceptance of HPV vaccination. By identifying and addressing these complexities, WDCs can devise practical solutions and share experiences to facilitate broader implementation of effective strategies across the nation. In essence, leveraging the collaborative efforts of WDCs and local stakeholders is essential for accelerating the uptake of HPV vaccination and advancing the broader goals of universal health coverage in Nigeria. Through proactive community engagement and participatory decision-making, barriers to healthcare access can be dismantled, paving the way for equitable and inclusive healthcare delivery nationwide (Anorlu et al., 2010; Ahmed et al., 2013; Awolude et al., 2013; Denny et al., 2014; Nguyen et al., 2020; Elemuwa et al., 2024b; Kakwi et al., 2024)

7.1 Successful examples where the WHS in Nigeria has contributed to improving demand and acceptance of health interventions

Throughout various states, Ward Development Committees (WDCs) have achieved notable successes in enhancing the quality of healthcare services delivered by frontline health workers and stimulating increased demand for healthcare services. Their efforts have led to tangible improvements, including the mobilization of resources for infrastructure renovation, maintenance of health facilities, and the provision of support for temporary healthcare staff. By engaging in routine supervision and active participation, WDCs have played a pivotal role in driving these advancements (Farmer, 2016). Moreover, WDCs have been instrumental in fostering community engagement and awareness regarding health-related issues. Through initiatives such as routine community sensitization and dialogue conducted during town hall meetings and community gatherings, WDCs have effectively disseminated vital health information and promoted discussions on factors influencing health outcomes. Many WDCs have also spearheaded campaigns to promote sanitation and hygiene practices within their respective communities, contributing to overall improvements in public health (Olalekan et al., 2018; Raimi et al., 2018; Henry et al., 2019; Raimi et al., 2019f; Gift and Olalekan, 2020; Gift et al., 2020; Olalekan et al., 2020b; Morufu et al., 2021; Kakwi et al., 2024; Elemuwa et al., 2024a,b).

Furthermore, WDCs have undertaken extensive efforts to support immunization interventions by facilitating line-listing and defaulter-tracking activities. By meticulously monitoring immunization records and identifying individuals at risk of missing vaccinations, WDCs have played a crucial role in ensuring comprehensive vaccine coverage and safeguarding community health (Allen and West, 2016; Goldie et al., 2008).

Overall, the successes achieved by WDCs underscore their indispensable role as grassroots advocates for healthcare improvement. Through their dedication and proactive engagement, WDCs have demonstrated their capacity to drive positive change and foster community empowerment in the realm of healthcare delivery. Their multifaceted contributions serve as a testament to the effectiveness of collaborative community-based approaches in addressing healthcare challenges and advancing the collective well-being of communities across the nation.

7.2 Key factors that have contributed to the success of the WHS in improving demand and acceptance of health interventions

In regions where Ward Development Committees (WDCs) have effectively overseen the implementation of the ward health system, deliberate and inclusive strategies have been employed to harness its potential in enhancing the demand for and access to healthcare services and interventions. These strategies have been characterized by a concerted effort to explore and maximize the role of the WHS in addressing community health needs (Christopher et al., 2024b). Furthermore, instances of robust and purpose-driven revitalization initiatives spearheaded by WDCs have emerged, buoyed by strong governmental leadership, substantial financial investments, and support from donors and partners. These initiatives have been strategically aligned with existing national guidelines, ensuring coherence and efficacy in their execution. The concerted efforts of stakeholders, including government entities, community leaders, and external partners, have synergistically contributed to the success of these endeavors. Moreover, the presence of ample healthcare supplies, including those essential for specific healthcare interventions, has bolstered the capacity of healthcare facilities to meet the escalating demand for services. This increased capacity has been facilitated by the sustained advocacy and mobilization efforts of WDCs, which have effectively galvanized community support and participation. In essence, the collective commitment to leveraging the potential of the ward health system has yielded tangible results, marked by improved healthcare access and service delivery in areas where WDCs have been proactive and empowered. By aligning strategies with national guidelines, securing adequate resources, and fostering community engagement, WDCs have played a pivotal role in driving positive health outcomes and advancing the overarching goals of healthcare accessibility and equity (Christopher et al., 2024a; Mordecai et al., 2024; Kakwi et al., 2024; Elemuwa et al., 2024a,b).

7.3 Replicating lessons learned for fast-tracking demand and acceptance of HPVV through the WHS

Over the years, the Nigerian healthcare sector has established comprehensive guidelines to steer its strategic direction. Yet, translating these guiding principles into tangible outcomes necessitates collaborative efforts from all stakeholders to identify and amplify effective strategies. Notably, successful initiatives, such as a Health Development Partner’s collaboration with dedicated community volunteers, have yielded remarkable results. For instance, in Bauchi state, a Ward Development Committee (WDC)-led Emergency Transport System (ETS) facilitated the transportation of 23,083 pregnant women for antenatal care, 15,989 women for childbirth, and 16,279 children under five for healthcare services. Recognizing the impact of such interventions, the development partner pledged continued collaboration with WDCs to enhance gender integration and expand the pool of women ETS drivers in Bauchi and other states. This underscores the importance of stakeholders mapping out strategies that harness the presence and influence of WDCs effectively. Establishing a comprehensive program framework, supported by adequate funding and resources, is crucial for replicating successful approaches nationwide. Therefore, it is imperative to consolidate mechanisms for tailored community engagement and participation, particularly in expediting the demand and acceptance of HPV vaccination through the ward health system. WDCs, equipped with localized insights, are well-positioned to identify the nuances influencing HPV vaccination demand within their communities. By analyzing these dynamics, devising solutions, and sharing best practices, WDCs can contribute to the widespread adoption of effective approaches, thereby advancing HPV vaccination targets nationwide.

8.1 Potential barriers and challenges to fast-tracking demand and acceptance of HPVV through the WHS

In recent years, the Ward Development Committees (WDCs) have made significant strides in mobilizing communities and dismantling barriers rooted in religious and cultural norms that hinder health-seeking behavior. However, concerns have been raised regarding the insufficiency of supplies within healthcare facilities, posing a significant challenge that undermines the efforts of WDCs. This deficiency threatens to impede locals from accessing essential health services and jeopardizes the progress achieved by WDCs. Therefore, ensuring the consistent availability of HPV vaccine supplies across primary healthcare facilities nationwide is paramount. Despite the relentless efforts of WDCs in addressing religious and cultural barriers to health-seeking behavior, challenges persist in certain areas. Addressing these challenges may necessitate stronger engagement with traditional and religious leaders, who can influence the acceptance of HPV vaccination and shape the attitudes of community members toward seeking healthcare services.

Moreover, it is imperative to adequately incentivize WDCs to recognize and appreciate their contributions to advancing the Nigerian healthcare system through the implementation of the Ward Health System. Collaborative efforts between the government and partners at all levels are essential in establishing a framework for acknowledging the efforts of WDC members and providing incentives to sustain their commitment. Recognizing the pivotal role of WDCs, especially in maintaining optimal levels of demand and acceptance of the HPV vaccine nationwide, is crucial for sustaining progress. Furthermore, there is a need to holistically evaluate coordination frameworks governing the operations of WDCs, as outlined in relevant national guidelines. It is essential to assess the extent of implementation of these frameworks and ensure their consolidation across all states and local government areas of the federation. Nigeria must continually monitor the operationalization of WDCs, ensuring alignment with their terms of reference and maximizing their potential impact on community health.

8.2 Solutions and recommendations to address the challenges

In proffering a strategy for leveraging WDCs for fast-tracking demand and acceptance of HPVV across Nigeria, all stakeholders must provide enabling circumstances for the WDCs to play the vital roles they can:

Tailored to the HPV vaccination programme:

8.3 Importance of collaboration between various stakeholders

Addressing the multifaceted challenges within Nigeria’s expansive healthcare sector demands a collaborative approach from all stakeholders to accelerate the adoption of HPV vaccination nationwide. Despite the commendable efforts of Ward Development Committees (WDCs) in advancing healthcare initiatives, numerous states continue to grapple with obstacles such as insurgency activities, widespread ignorance, hospital avoidance tendencies, delays in seeking medical care, and entrenched traditional practices prevalent in rural communities. However, signs of progress are evident, particularly in bolstering routine immunization services (Raimi et al., 2017; Raimi et al., 2019e; Elemuwa et al., 2024a), thanks to strategic collaborations like the Memorandum of Understanding (MOU) between the Bill and Melinda Gates Foundation (BMGF), Aliko Dangote Foundation (ADF), and select state governments. This partnership underscores the importance of synergizing efforts between government bodies and non-state actors to enhance healthcare accessibility and coverage, aligning with the overarching principles outlined in the 2014 Presidential Summit Declaration on Universal Health Coverage (UHC) in Nigeria. The enduring relevance of this declaration emphasizes Nigeria’s imperative to cultivate existing partnerships and forge new ones across multiple sectors to orchestrate a cohesive UHC agenda. Led by governmental initiatives and bolstered by the support of diverse non-governmental entities, these collaborative endeavors serve as pivotal conduits for driving comprehensive healthcare reforms and expanding access to essential services across the nation.

9.1 Linking the ward health system and fast-tracking of demand and acceptance of HPVV in communities

Primary Health Care (PHC) is the foundation of any country’s healthcare system, acting as the first point of contact for people, their families, and their communities. Positioned as the cornerstone of universal health coverage (UHC), PHC endeavors to bring healthcare services within close reach of where people reside and labor, establishing a foundational continuum of care. This principle underscores the fundamental ethos of ensuring health equity and accessibility for all. Integral to the realization of UHC objectives is the robust implementation of primary healthcare, which serves as the conduit for dispensing essential healthcare services to diverse populations. Within this framework, the ward health system emerges as a linchpin for extending comprehensive healthcare access to communities, rooted in pragmatic, evidence-based, and culturally sensitive approaches (Raimi and Raimi, 2020; Raimi et al., 2020; Morufu et al., 2021; Raimi et al., 2021a, b; Elemuwa et al., 2024b). Central to the operational efficacy of the ward health system are the Ward Development Committees (WDCs), which assume a pivotal role in orchestrating community engagement and participation. Tasked with providing managerial support to the ward health system, WDCs play a paramount role in fostering holistic community involvement, ensuring that healthcare interventions are not only financially sustainable but also resonate with the ethos of self-reliance and self-determination. To navigate the complexities surrounding the uptake of HPV vaccination (HPVV), it is imperative to devise comprehensive, community-centric strategies. Such initiatives necessitate close collaboration with community stakeholders to design, execute, and assess vaccination programs effectively. Given the profound influence of public perceptions on vaccination strategies, the Ward Health System (WHS) emerges as a vital catalyst for elucidating and positively shaping community attitudes towards HPVV, thereby enhancing demand and acceptance rates.

9.2 Significance of leveraging the WHS for fast-tracking demand and acceptance of HPVV

The imperative for expediting the uptake of HPV vaccination (HPVV) underscores the necessity for implementing a sustainable vaccination strategy grounded in comprehensive community-based approaches. This entails fostering close collaboration with community members at every stage of the vaccination process, encompassing planning, implementation, and evaluation. At the forefront of orchestrating this crucial community engagement stands the ward health system, serving as the conduit for coordinating grassroots involvement. Through the concerted efforts of constituted and operational ward development committees (WDCs), the ward health system has yielded tangible results, fostering improved health-seeking behavior and enhanced overall health outcomes across diverse localities. These committees, embedded within the fabric of their communities, serve as catalysts for driving meaningful change through their proactive engagement and strategic interventions. The successes achieved by WDCs in advancing the principles of the ward health system underscore the pivotal role of purposeful and dedicated initiatives aimed at reactivating these committees. Such endeavors, bolstered by strong governmental leadership, substantial funding allocations, and robust support from donors and partners, have been instrumental in executing strategies aligned with national guidelines. These concerted efforts have not only revitalized the operational capacity of WDCs but have also fortified their ability to drive impactful interventions at the grassroots level (Oyeyemi et al., 2021, 2022). In essence, the convergence of community-based approaches facilitated by the ward health system, coupled with the resolute commitment of WDCs, epitomizes a holistic strategy for expediting the demand and acceptance of HPVV. This collaborative framework, underpinned by effective coordination and sustained support, holds immense promise in fostering widespread vaccination uptake and realizing tangible health gains across communities.

9.3 Potential impacts of leveraging the WHS for fast-tracking demand and acceptance of HPVV

At the institutional level, the national operational guidelines governing the activities of the ward development committees (WDCs) serve as a foundational document, delineating the parameters for committee composition, gender representation quotas, meeting schedules, and election protocols. Adhering rigorously to these guidelines holds the potential to enhance the appeal of WDC participation and establish robust standards for their revitalization. However, substantial strides are imperative to reactivate or consolidate the functionality of WDCs across the various states of the federation. A critical aspect necessitating attention is the augmentation of the current development partner support portfolio allocated to bolstering the functionality of WDCs, particularly in instances where comprehensive support is lacking. State and local governments must exhibit greater proactivity in prioritizing the creation of conducive conditions conducive for WDC operations within their jurisdictions, thereby catalyzing substantial improvements in health outcomes on a broad scale. Furthermore, deliberate efforts are essential to fortify coordinated initiatives that foster collaboration, recognition, health promotion activities, awareness campaigns, incentives, community engagement, and orientation of WDC members on operational guidelines. These facets significantly influence the efficacy of the ward health system in fulfilling its mandates and driving positive health outcomes within communities. In the context of the Nigeria HPV vaccination strategy, harnessing the potential of the ward health system is pivotal in galvanizing increased demand and acceptance of HPVV. This involves facilitating the implementation of the vaccination agenda through comprehensive community-based engagements that foster close collaboration with community members at every stage, from planning to evaluation. Given the profound impact of public perceptions on vaccination strategy effectiveness, the ward health system assumes a crucial role in elucidating and positively shaping community attitudes towards HPVV in a sustainable manner.