Integrating HPV Education Into School Health Programs in Cambodia and Kenya

This implementation research study evaluated the integration of HPV education intoexisting school‐based health education initiatives in Cambodia and Kenya using amixed‐methods, cluster‐level difference‐in‐differences design.Study setting, school selection, and arm‐assignment procedures varied by country. InCambodia, Kampong Cham and Kratie provinces were purposively selected based onoperational feasibility, relatively low HPV vaccination coverage, differing urban‐ruraland service‐access contexts, and support from the School Health Department. From a frameof 730 schools, 46 schools with larger numbers of age‐eligible girls were selected andallocated 1:1 using operational district, urbanicity, and random‐number ordering. InKenya, Nairobi, Kilifi, and Migori counties were purposively selected to representdiverse implementation settings. An initial 160 schools were randomly sampled from anoperational school‐health facility mapping list. In Nairobi and Kilifi, schools weregrouped geographically by ward and the resulting groups were randomly assigned tointervention or control. Before baseline, stakeholder validation led to replacement of 25Nairobi and 6 Kilifi schools, with replacements retaining the original study arm. InMigori, 18 of the original 52 schools were replaced following county validation; thecorrected 52‐school roster was then randomized 1:1 at school level without ward grouping.The final study included 46 schools in Cambodia (23 intervention, 23 control) and 160 inKenya (80 intervention, 80 control).The intervention was educational. In Cambodia, the package targeted Grades 3‐5 andintegrated HPV content into existing sexual and reproductive health education. In Kenya,it targeted Grades 4‐8 during implementation and integrated HPV content into existingschool health education; these cohorts progressed to Grades 5‐9 by the January 2026endline assessment. Trained teachers delivered the education during routine schoolactivities. HPV vaccination itself was not assigned or modified by the study; nationaleligibility, products, schedules, supply, and delivery arrangements remained unchanged.Quantitative outcomes were assessed at baseline and endline. HPV vaccination coverageamong age‐eligible girls was assessed primarily from school immunization records,supplemented by linked health‐facility records in Kenya where needed; EPI data inCambodia and KHIS data in Kenya were used for validation and sensitivity analyses.Student knowledge, awareness, attitudes, and sexual and reproductive health knowledgewere assessed using independent repeated cross‐sectional KAP questionnaires in sixschools per country. Country‐specific intervention effects were estimated usingdifference‐in‐differences analyses.Qualitative interviews with caregivers, teachers, and healthcare workers assessedHPV‐related knowledge and vaccination perceptions, accessibility, and implementationfeasibility and acceptability. Cost data were collected to estimate the cost perimmunization administered under the intervention model. Actual enrollment comprisedparticipants contributing directly collected KAP or qualitative data; vaccinationcoverage analyses used de‐identified routine records and did not require individualenrollment.Four Migori schools had intervention exposure that differed from their assigned studyarm: two control‐assigned schools received the intervention and two intervention‐assignedschools did not. All four were retained in their assigned arms for analysis under anintention‐to‐treat approach.The study received country‐specific ethics approval from the National Ethics Committeefor Health Research in Cambodia and the Amref Ethics and Scientific Review Committee inKenya. Subsequent amendments or continuations were approved before extended studyactivities, including January 2026 endline data collection.