“This Is Something Every Woman Needs. . .So Why Is It That Expensive?”: Examining Privileges and Inequities in Access to a Privately Funded HPV Vaccination Program in Ghana

Abstract

The age-standardized incidence and mortality rates for cervical cancer in Ghana is 27.4 and 17.8 per 100,000 women, respectively. Currently, HPV vaccination is available only through privately funded programs, leading to inequitable access and uptake. This study examined how intersecting identities, and social locations contribute to inequities in the privately-funded HPV vaccination program in Ghana. We used an intersectionality-guided qualitative case study design. Data collection included non-participant observation of the clinic context and semi-structured interviews with HPV vaccine recipients (N = 13). We found that participants’ access to HPV vaccination was shaped by socioeconomic privileges, including the ability to afford the vaccine. Their narratives revealed significant challenges in accessing HPV vaccination and highlighted how intersecting identities contribute to inequities in the privately funded program. Participants reported a general lack of HPV vaccination information in Ghana and often learned about the vaccine through incidental means. Conservative sociocultural norms surrounding sex, sexuality, and reproductive health were significant barriers, particularly in facilitating adolescent-parent discussions about HPV vaccination. Given the inequities reported by vaccine recipients, there is a critical need for education campaigns that raise awareness of the benefits of HPV vaccination, alongside strategies to support socioeconomic empowerment. Addressing these barriers through an inclusive public health policy will help prevent replicating the inequities seen in the privately-funded program and reduce HPV-related diseases, particularly cervical cancer.

Background

Despite vast evidence of the benefits of human papillomavirus (HPV) vaccination in preventing HPV-related diseases (Setiawan et al., 2024; Wang et al., 2022), HPV vaccination access remains low in limited-resource regions of the world (Asgedom et al., 2024; Fokom Domgue et al., 2024). Ghana has one of the highest HPV-related disease burdens globally, with age-standardized incidence and mortality rates for cervical cancer at 27.4 and 17.8 per 100,000 women, respectively (Bruni et al., 2023). These figures are nearly four times the global age-standardized incidence rate of 6.8 and five times the global age-standardized mortality rate of 3.4 per 100,000 women (Yang et al., 2022). Yet, HPV vaccination in Ghana currently has no national insurance coverage and is only available through privately-funded programs in a few government hospitals and private clinics (International Vaccine Access Center [IVAC], 2023).

Without a publicly-funded vaccination program, individuals must self-fund their HPV vaccination, but this leads to inequitable access and uptake. Specifically, the cost of the private HPV vaccination may prevent individuals from low socio-economic backgrounds from taking the vaccines, resulting in inequitable vaccination access to disadvantaged populations. However, financial barriers alone do not fully explain these inequities, as other social factors also influence access to vaccination (Chiara et al., 2023). Plans to introduce a publicly-funded HPV vaccination in Ghana began last year (3 News, 2024), with a nationwide campaign initially targeting girls aged 9 to 14 years scheduled for September 2025 (World Health Organization [WHO], 2025). This campaign will be followed by the integration of HPV vaccination into the routine immunization program (WHO, 2025). Given these developments, it is critical to examine how the various social factors (e.g., identity, geographic factors, cultural beliefs and norms, parental education, etc.) interact with these economic barriers to understand the broader factors that shape HPV vaccination.

Vaccination is not only a biomedical issue but also a social process influenced by numerous factors such as culture, identity, history, geography, and politics (Chiara et al., 2023; Dubé et al., 2013; Nuwarda et al., 2022; Rodrigues et al., 2022). These social factors shape how individuals perceive and access vaccination services. In a context like Ghana, where HPV vaccination is not covered by national health insurance and where significant socio-economic disparities exist (Novignon et al., 2019; Oduro et al., 2018), these factors are especially important in influencing healthcare access, including HPV vaccination. Thus, understanding how these intersecting identities and locations shape HPV vaccination access is essential for addressing the root causes of inequities in HPV vaccination in Ghana.

Yet, most studies on HPV vaccination in Ghana have focused primarily on knowledge, awareness, attitudes, perceptions, and vaccine acceptance, often treating these factors as isolated influences (Ampofo et al., 2023; Appiah et al., 2023; Asare et al., 2020, 2023; Osei et al., 2021; Popelsky et al., 2022; Williams et al., 2019). Additionally, in studies that explored HPV vaccination knowledge and awareness (Drokow et al., 2020; Osei et al., 2021), there were knowledge gaps in how social identities (i.e., the various ways in which individuals define themselves in relation to the groups they belong to or associate with (Leaper, 2011) and social locations (i.e., their position within the larger socioeconomic and political context [Daynes, 2007]) intersect and shape how individuals learn about HPV vaccination and services in a context where there are no publicly-funded programs. A recent review from Canada (Cha et al., 2023) has highlighted the limited attention given to how the intersection of individual identities and social locations contributes to inequities in vaccination research. Similarly, in resource-limited regions like Ghana (Marfo et al., 2022), these intersecting factors remain underexplored, leaving a critical gap in our understanding of vaccination inequities.

This study aimed to investigate how intersecting identities, and social locations contribute to inequities in HPV vaccination access in Ghana. Specifically, we sought to answer the following research questions: (a) How do social identities and locations shape the process of knowing about and receiving HPV vaccination in Ghana, and (b) how accessible is the privately funded HPV vaccination program in Ghana? This study will bridge the gap in our understanding of how processes of knowing and receiving HPV vaccination in Ghana are shaped by these complex and intersecting identities and locations. Furthermore, this study will contribute evidence to inform policy on the pending publicly-funded program and existing privately funded HPV vaccination programs, particularly on vaccine delivery, communication, and messaging, which will support equitable HPV vaccination access in Ghana and similar contexts.

Methods and Materials

Theoretical Approach: Intersectionality

This study was underpinned by intersectionality theory, which has its roots in critical race and Black feminist scholarship (Crenshaw, 1989). Emerging in response to the exclusive second-wave feminism that failed to recognize the problems of Black women due to their unique intersections of gender and race (Lawrence, 2017), the fundamental assumption of intersectionality theory is that multiple coexisting identities (e.g., race, gender, sex, income, and parental education) and social locations (e.g., class) mutually intersect in a complex fashion to create, (re)produce, and sustain power differentials between unique privileged and disadvantaged positions (Carastathis, 2014; Crenshaw, 1989). According to intersectionality, it is methodologically challenging to comprehensively understand experiences by relying on monolithic research practices that consider individual identities or social locations as separable and independent subjects of inquiry (Bauer, 2014; Carbado et al., 2013).

Therefore, intersectionality offers an appropriate lens to understand the complex interplay of identities and locations that shape HPV vaccination experiences and access in Ghana. Literature from the international context shows that different intersections of sex, race, gender, religious affiliation, family income, education, HIV-status, and parental literacy are relevant modifiers of HPV vaccination acceptance, access, and uptake (Branković et al., 2013; Kornides et al., 2019; Smolarczyk et al., 2022) across diverse communities, justifying the appropriateness of applying an intersectional lens in exploring inequities in HPV vaccination accessibility in the Ghanaian context.

However, it is important to recognize that the axes of inequities examined in intersectional analyses are shaped by specific geo-socio-historical contexts and may not hold the same relevance across settings (Golash-Boza, 2016; Hill, 2015). For example, while intersectionality is rooted in observations of minoritized groups in the United States who experience overlapping marginalizations, such as those related to race and gender identity (Collins, 2015; Crenshaw, 1989; Hankivsky et al., 2014), the meanings and impacts of these categories vary globally. In Ghana, for instance, race and ethnicity may not shape health experiences in the same way they do in North America. For example, the lead author (Emmanuel Marfo) became aware of his “Blackness” only after migrating to Canada. In Ghana, social identity is primarily organized around tribal affiliation, while foreigners with light skin are broadly labeled “Obroni” regardless of their racial background. These differences highlight that constructs like race and color are conceptualized differently in Ghana and may not be salient determinants of health in the same way they are in Western societies. Therefore, in this study, we were attentive to only relevant intersecting identities and social locations in the Ghanaian context.

Our use of intersectionality granted us theoretical insights into examining the conflation of pertinent individual and social determinants, including privilege, and the consequent influence on HPV vaccination access. By adhering to intersectionality theoretical principles, we maintained a reflexive stance throughout the project, constantly reflecting on our diverse positions and power as a team of researchers and healthcare providers with nursing backgrounds.

Researchers’ Characteristics and Reflexivity

We are a team of four researchers based in Canada (n = 3) and Ghana (n = 1) with diverse identities across race, ethnicity, gender, sex, linguistic backgrounds, and geographic origins (Canada, Ghana, and Nigeria). The team was comprised of experts in HPV vaccination, health policy, case study research design, intersectionality theory, and sexually-transmitted and blood-borne infection research. Emmanul Marfo, who received undergraduate nursing education in Ghana, brought valuable cultural context to the study. The second author, Charles Adjei also possessed contextual understanding and facilitated domestic ethical and administrative processes. We regularly reflected on how our positionalities influenced the research process, from participant recruitment (e.g., ensuring diversity in identities and social locations) to data analysis (e.g., documenting thoughts and feelings and seeking insights from the research team). Our combined expertise and multi-perspective lenses supported all phases of the study, from conceptualization and data collection to analysis and writing, with ongoing consultations to guide the study.

Design

This study was part of a larger project that explored a privately-funded HPV vaccination program in Ghana. The project was guided by a qualitative case study research design as described by Robert Yin (Croni, 2014; Yin, 2018), which offers an in-depth investigation of a contemporary phenomenon using multiple methods (e.g., observation, semi-interviews, and triangulation of data sources). This design was appropriate for the project because it allowed for a comprehensive exploration of the privately-funded HPV vaccination program.

To provide context for the case study, the Greater-Accra Regional Hospital was the “case” for the project, and the privately-funded HPV vaccination program between 2019 and 2023 was the “unit of analysis”. We included HPV vaccinators (i.e., clinic staff who provide HPV vaccines), program/policy leaders (i.e., hospital administrative staff, directors of health involved in policy making at the national level, and private HPV vaccine suppliers), and HPV vaccine recipients (i.e., individuals who received HPV vaccines from the clinic) at the hospital to explore the unit of analysis. In a previous article, we focused on insights from vaccinators and program/policy makers about the HPV vaccination program (Marfo et al., 2024). This article reports on different findings and complements that work by examining the experiences and perspectives of vaccine recipients, with a particular focus on the inequities and challenges they faced in accessing the HPV vaccination at the clinic.

Study Context: Ghana and Hospital

Ghana, a West African country with a population of approximately 35 million as of July 2024 (World Population Review, 2024), operates a three-tier healthcare delivery model overseen by the Ministry of Health. The system consists of primary, secondary, and tertiary levels of care across various facilities. At the primary level, care is provided by health centers and Community-Based Health Planning and Services Compounds, primarily serving rural and remote populations (Novignon & Nonvignon, 2017). At the secondary level, care is offered by health facilities at district, municipal, and regional capitals, focusing on diagnostics, treatment of acute conditions, emergency care, minor surgeries, and Caesarean sections (Asamani et al., 2018). The tertiary level facilities serve as autonomous referral teaching hospitals that specialize in complex health interventions and are affiliated with major universities for professional training and research (Asamani et al., 2018).

The study was conducted at the Greater-Accra Regional Hospital, a tertiary hospital, located in the Osu-Klottey Sub-Metro of Accra. Established in 1928, the hospital serves as a regional referral health facility that provides comprehensive health services for over 4.6 million people in the Greater-Accra Region and its environs (Greater Accra Regional Hospital, 2025). This hospital was chosen for the study due to its established cervical cancer prevention programs and being among the few facilities with an established HPV vaccination initiatives in Ghana. In this hospital, the HPV vaccination program is delivered at the Family Planning Unit under the Department of Obstetrics and Gynecology. The Family Planning Unit, staffed by eight nurses (vaccinators), independently manage all aspects of their HPV vaccination programs, including procurement, administration, and follow-up, with both service and vaccine costs directly paid by patients under a “cash and carry” system.

Participant Recruitment

Initially, we aimed to include only adolescents aged 11 to 19 years who had received the HPV vaccine from the Family Planning Unit of the hospital between 2019 and 2023, as this group is the primary target for most HPV vaccination programs (WHO, 2022a). A trained clinic staff member shared brief information about the study with parents or guardians (n = 25) of adolescent HPV vaccine recipients. The lead author then contacted interested parents to provide more details about the study and schedule an interview (n = 5). However, due to the limited number of interested parents, we extended eligibility to include vaccine recipients aged 19 to 45 years. Clinic staff shared study information with selected members of this older group (n = 60), and the lead author followed up with those who expressed interest (n = 8), providing detailed information and scheduling interviews. In total, 13 HPV vaccine recipients out of the 85 participants contacted, completed the interviews. No participants were excluded based on identity, language, or sociodemographic factors. Additionally, the clinic staff were not aware of which vaccine recipients eventually completed interviews for the study.

Data Collection

Data collection included clinic observation and interviews. The lead author conducted a non-participant descriptive observation at the Family Planning Unit for approximately 3 weeks, allowing for prolonged engagement and persistent observations (Smit & Onwuegbuzie, 2018). The lead author visited the clinic on various mornings and afternoons, excluding weekends when the clinic, did not operate for observations (Busetto et al., 2020). The focus of the observation was on routine clinic events (e.g., patient flow), social dynamics (e.g., patient-staff and staff-staff interactions), and operational processes (e.g., organizational practices). No pre-designed checklist was used for the observation to allow the ability to capture the unique features and events that do not fit into a priori categories (Fetters & Rubinstein, 2019). While the observation aimed to explore the broader context of the clinic’s functioning, direct observation of staff-patient interactions during care delivery was excluded to ensure patient safety and privacy. The lead author documented observations in fieldnotes, including initial reflections, the physical environment, interactions, and descriptive accounts of activities.

We developed a semi-structured interview guide based on relevant HPV vaccination literature (Ampofo et al., 2023; Appiah et al., 2023; Asare et al., 2020; Marfo et al., 2022). The research team reviewed the guide, which focused on HPV vaccination information, access, and experiences in the hospital (see Supplemental File 1). The interview guide was piloted to determine cultural appropriateness and revised upon feedback. The lead author obtained written informed assent and consent from adolescent participants and their parents respectively. Adult participants provided written informed consent before interviews. The lead author completed semi-structured interviews with the vaccine recipients of an average duration of 29 minutes in English (the official language in Ghana) from October 1 to November 6, 2023. After the 13th interview, the research team concluded that the data collected were sufficient to address the research questions, based on a review of interview transcripts and fieldnotes (Braun & Clarke, 2021). Participants received 50 Ghana Cedis (CAD 7) in appreciation of their contribution to the study, and those whose participation involved travelling were reimbursed for the travelling expenses. We recorded all interviews on digital recorders. All transcripts were transcribed data verbatim by a research assistant and anonymized with pseudonyms. We conducted member-checking to ensure data accuracy with four randomly-selected participants (Birt et al., 2016).

Data Analysis

The fieldnotes were read iteratively and analyzed using narrative summaries. These observational data were used to contextualize participants’ accounts and enrich the interpretation of interview findings, particularly regarding access-related barriers and the broader clinic environment. We analyzed interview data using an inductive thematic approach (Gale et al., 2013). The intersectionality theory, interview guide, and extant literature informed coding of transcripts (Gale et al., 2013). The lead author inductively coded all transcripts using NVivo software version 12 (QSR International, Burlington, MA) to identify evidence of intersecting identities that shaped privileges and inequities in HPV vaccination access and experiences. A research assistant coded four transcripts independently in duplicate (Atkins et al., 2017). The lead author and research assistant validated codes through discussions by comparing and identifying aligned codes and resolving conflicts to create the final analytical framework for iterative coding. Codes were finally discussed with the project supervisor (Shannon MacDonald) for feedback and modification. The lead author actively categorized codes into relevant themes, which were constructed through an iterative and interpretive process of data analysis. The intersectionality theoretical lens aided us in recognizing the privileged and perceived disadvantages and experiences embedded in participants’ responses about their HPV vaccination. In our analysis, we were also attentive to relevant identities (e.g., sex, age, social class, employment, and parental socio-economic status).

Scientific rigor was maintained through ongoing reflection on recorded memos and field notes, as well as triangulation of data sources, including both interview and observation data. An audit trail was kept to document decisions made during data collection and analysis, ensuring transparency and reproducibility. Throughout the study, the lead author regularly consulted with the project supervisor and research team to gather insights on study execution and analysis. Additionally, we provided a rich, anonymized description of study participants to support contextual understanding. Collectively, these strategies contributed to the credibility, dependability, confirmability, and transferability of the study’s findings.

Ethics

The research team obtained ethical approval from the University of Alberta Research Ethics Board (Pro00124946) and the Ghana Health Service Ethics Review Committee (Protocol ID No: GHS-ERC 003/09/23). In addition, permission to conduct the study was granted by the Greater Accra Regional Directorate of Health. All interviews were conducted in private, supportive settings to ensure participant comfort and confidentiality. Participation was entirely voluntary, and participants were informed that they could withdraw from the study at any time without consequence. To protect participants’ identities, pseudonyms have been used throughout the reporting of findings.

Results

Clinic Context and Participant Characteristics

The HPV clinic is based at the Family Planning Unit of the Obstetrics and Gynaecological Department and is accessed through the main Out-Patient Department (OPD) of the hospital. On the entrance is a poster with an inscription that states “Family Planning Unit”. The flyer also talks about services available at the unit, which include the following: cervical cancer screening, family planning, breast cancer screening, cryotherapy, management of STIs, and other sexual and reproductive services. There are two long benches with a single table at the unit’s main entrance and another two benches in the unit. The Deputy Director of Nursing Services (DDNS) has a private office with a computer and the senior nursing staff also have a shareable office with a computer. There are three screened rooms for clients’ consultation. Opposite the DDNS’s office are the nurses’ changing room and the autoclave and decontamination room. Within the hallway of the unit was another flyer showing the images of the several stages of cervical cancers. There was a treatment room and an office for physicians and medical students on the unit.

Interview participants (N = 13) were females between 17 and 34 years old who had received HPV vaccines, including five adolescents and eight adults. Most participants (n = 8) had either finished or were in the process of completing post-secondary education. The parents of all adolescent participants (n = 5) were employed in “white-collar” jobs, whereas half (n = 4) of the adult participants were physicians or worked in a health organization (see Table 1).

Table 1.

Characteristics of Vaccine Recipients.

Participant	Gender, sex	Age	Education	Employment	Parental-employment
Araba	Girl, female	17	O Level	N/A	Professional
Bernice	Girl, female	18	Senior high school	N/A	Professional
Elsalsa	Girl, female	18	Senior high school	N/A	Professional
Adom	Woman, female	19	Undergraduate student	N/A	Professional
Hardley	Woman, female	19	Undergraduate student	N/A	Professional
Telli	Woman, female	23	Bachelor’s degree	Program assistant for non-profit international health organization	N/A
Mimo	Woman, female	25	Medical degree	Physician	N/A
Akumaa	Woman, female	28	Senior high school	Fashion designer	N/A
Manu	Woman, female	28	Medical degree	Physician	N/A
Dora	Woman, female	28	Senior high school	Micro-finance sales personnel	N/A
Emefa	Woman, female	29	Medical degree	Physician	N/A
Edith	Woman, female	31	Bachelor’s degree	Secretary	N/A
Annette	Woman, female	34	Master’s degree	Marketer	N/A

Note. All participants’ names are pseudonyms.

Overview of Interview Findings

Our analysis identified three major themes related to participants’ experiences, privileges, and perceived barriers that intersect to shape inequities in HPV vaccination access in Ghana. These themes are: (1) Navigating information deficits and responsibility in the search for HPV knowledge, (2) HPV vaccination decision-making, and (3) Navigating privilege, barriers, and cultural norms in HPV vaccine access (see Figure 1).

Figure 1.

Thematic map of qualitative findings related to intersecting inequities in HPV vaccination access.

Theme 1: Navigating Information Deficits and Responsibility in the Search for HPV Knowledge

Most participants reported a perceived HPV vaccination information deficit. They mentioned hearing about HPV vaccination by coincidence. These unplanned discoveries about HPV vaccination were mostly facilitated by privileged positions as healthcare professionals or parental relationships with health professionals. Most of the participants indicated that they wanted more information before their vaccination. Some participants took the initiative to seek information about HPV vaccination and services, while others expressed disappointment in the process.

The Paradox of an Invisible Public Health Issue and Information Deficit

Most participants perceived low education and awareness of HPV vaccination in the Ghanaian context. Adom (an adolescent participant) explained that “. . . it’s not really publicized like HIV campaigns and those things, so it’s not really a popular thing”. Some participants felt the HPV vaccination information deficit was general to most Ghanaians regardless of their education, status, or profession. For example, Hardley (an adolescent participant) asked, “How many people in Ghana know. . .?” She explained further that:

I feel like . . . they haven’t been given any information about it. They don’t know about it. Because so far, I haven’t heard any peers of mine, any new friends I even have in KNUST [a public university in Ghana], ever mentioning it at all.

Similarly, Manu (an adult participant) reflected on HPV vaccination information deficit among her peers during her medical professional training. She explained:

. . . People don’t really create much awareness. . . so when I was doing my housemanship [post-qualification medical internship], all of us, all those at the time during ward rounds, it was about 16 of us, and none of us had taken the vaccine. And I feel like medical students are there. . . there’s no awareness. Doctors are there, no awareness. . . Even if the medical personnel at least know, they will [. . .] be spreading the news. . . But even if they have not taken [it], then how about those out there?

Social and Professional Privilege as a Pathway to HPV Vaccination Discovery

Some adult participants reported learning about HPV vaccination coincidentally. Edith (an adult participant) recounted, “I don’t really have any knowledge about it. I just heard it on the news. And they were talking about it”. Also, Annette (an adult participant) explained:

. . . the vaccination [. . .] was mentioned to me through a friend who was actually asking if I know they offer the vaccines or they sell the vaccines in pharmacies here in Ghana. . . [that] piqued my interest in it and I was like I needed to know so I went to my Gynae.

Similarly, Hardley, discussed:

It was so coincidental, like my mom and I watched a telenovela, Telenovela! . . . and you can imagine a lady in it [had] human papillomavirus like out of nowhere and she couldn’t have kids. . . so I think it sort of kicked into her [mother] after what she had watched. . .

Other adolescents reported that they initially learned about HPV vaccination from their parents (i.e., mothers). Araba (an adolescent participant) indicated “My mom introduced it to me. She told me that I needed to get the HPV vaccine in order to prevent any future risks of getting cervical cancer”. Araba believed her mother had learned about HPV vaccination through a friend of hers who is a health professional. She expounded: “Her friend who was a nurse was the one who maybe told her about it [HPV vaccine] because she was the one who took care of the vaccination and everything when I came”.

Similar to adolescents whose parental connection with healthcare professionals privileged their HPV vaccination knowledge, some adult participants with backgrounds in medicine emphasized that their professional training gave them the privilege to learn about HPV vaccination. Manu explained: “So I think, I learned about it in medical school, but it was one of those topics like we were learning; cervical cancer, breast cancer, and that . . .”. Likewise, Telli (an adult participant), who works as a program assistant for an international non-profit health organization mentioned that she learned about HPV vaccination through her work. She explained that she learned about HPV vaccination at “[a non-governmental organization] because of the projects I’m working on. . . So, the women’s cancer project is actually on cervical and breast cancer. . . so I’ve had to do a lot of learning and unlearning here”.

Expected Information Prior to Vaccination

Almost all participants reported they had anticipated knowing more about HPV vaccines before their vaccination. Most participants indicated they wanted to know about the safety and side effects of the vaccines. Adom mentioned, “I just wanted to know if the vaccine would be safe for me. . . like it would not affect my system, my reproductive system”. Similarly, Araba discussed: “I wanted to know the side effects after getting it. If it’s any serious thing that will cause pain [. . .] somewhere else in the body or like how important it is to have the vaccination. . .”. Some participants expressed interest in knowing the composition of the vaccine and its benefits. Elsalsa (an adolescent participant) mentioned: “I should have known a little bit more about it. . . I was just concerned if the vaccine is like a reduced version of the virus itself” whereas Bernice (an adolescent participant) stated, “I think they should have told me what it was for and why we were doing it”

The Burden of Individualized Vaccination Responsibility

Some participants indicated that they searched for their own information to familiarize themselves with HPV vaccination. For instance, Hardley explained, “I got fed up and I was like, I have to find my own [. . .] way of knowing what exactly is going inside my body, what it’s doing, and all that”. However, such information search required self-empowerment and the privilege to have access to information and possess health literacy skills. Emefa (an adult participant) conveyed that “so, in terms of information, I think my background as a medical personnel or medical doctor affected my access to information”. Similarly, Akumaa (an adult participant) narrated her experience:

So, I think I did the HPV test [. . .] when the result came, [. . .] I have the HPV 16 strain. . . So, I asked the doctor if I could take the vaccine [. . .]. I was asking questions and all that. He was like, no, I can’t take the vaccine because already I have it [HPV 16]. Then I read, I read more about it and then realized I can still take the vaccine. But I have to find out for myself. . . Yes, I have to. . . Even if I’ve not read, I’ve not been curious and all that, I wouldn’t have known.

One adolescent participant blamed herself for not searching for HPV vaccination information with the assumption that it was her responsibility. Araba discussed:

I should have taken the responsibility to research on the internet to get to know more. So, I feel like I should have, it’s like a fault of mine to have not gone to research on it [HPV vaccination] to get more knowledge on it.

Other participants expressed their displeasure about the challenges of locating HPV vaccination services. Manu (an adult participant) explained:

Yes, I called other hospitals. . . they did not have it at all. I know, I tried Adabraka Polyclinic, and that’s like one of the national centres for vaccination and unfortunately, they didn’t have it. I was so disappointed. . . we went and it wasn’t there. I was like, the National Center for Vaccination and they didn’t even have it. I was so disappointed.

Theme 2: HPV Vaccination Decision-Making

Participants shared several reasons for deciding to vaccinate against HPV. The adolescent participants indicated that their HPV vaccination was mainly decided by their parents. The vaccination decisions of most adult participants were influenced by their past experiences with individuals who had cancer, either through their work as medical professionals or through familial relationships. Some adolescent participants felt it was too early to receive HPV vaccines at adolescence, whereas most adult participants expressed disappointment about the late receipt of their vaccine uptake.

Parental Role and Lived Experience as HPV Vaccination Motivation

According to the adolescent participants, the decision to receive the HPV vaccines was mainly made by their parents. Elsalsa explained: “My parents just said I’m supposed to come and take a vaccine. . . she said I have to come and prevent cancer and all sorts of. . .” whereas Bernice shared that “. . . my mother made me do it. . . she brought me here to get the vaccination. . .”. Some adolescents’ accounts of their HPV vaccination decisions reflected absolute parental power in their HPV vaccination decision-making. Adom recounted: “She [mother] insisted that we go. . . I don’t have a choice. I was asking her questions. She was like, “I shouldn’t ask her questions and when I get there, I should ask them [nurses] and they will explain”. Furthermore, Araba explained adolescents are disempowered to access HPV vaccination independently: “. . . if the person is under the age of 18, it’s their parents or guardians who can help them get this vaccine”.

Some adult participants indicated that their vaccination decisions were motivated by past experiences with someone who had cancer. Edith disclosed how her mother’s experiences with cancer influenced her decisions. She explained:

Because my mother was a cancer patient. . . so I know how it is . . . So, if there’s something that we have to protect ourselves [. . .] and there’s vaccination, I think it’s important for everybody to like to take part of it.

Also, other participants with medical/healthcare backgrounds relayed that their experiences with patients with cancer diagnoses were one of the key factors that informed their decision to be vaccinated against HPV. Emefa explained that “the most important influence was the patients I saw with cervical cancer” whereas Mimo (an adult participant) further indicated that “I’ve seen twice [the] number of people with cervical cancer coming. So, yeah, it’s not a good diagnosis. So, it has influenced me. . .”

Generational Divide on the Timing of HPV Vaccination

Some of the adolescents indicated they were uncomfortable during their vaccination. Bernice explained: “When I came, the people that were there were quite old, and they were coming for the screening and things about the vaccine . . . I was shy”. Almost all the adolescents mentioned that they thought the vaccines were for older people. Elsalsa justified her thoughts:

I didn’t see any of [the] people I would think are my age mate. I mostly saw older women, and so I was wondering why I was there, because it looks like that’s something for older women and not for children.

Likewise, Adom explained “I thought when I’m grown like 30 years [old], I felt like I was too young for that” just like Araba who “[. . .] thought maybe I was too young for that”. Conversely, some adult participants regretted they had not received an early HPV vaccination. Emefa recounted: “. . . Oh, I wish I had gotten it earlier. . .Knowing what I know now, maybe in JSS [Junior Secondary School], I would have wished that I had gotten that information in JSS. And not just the information, but they come with the vaccines. . .” Similarly, Mimo (an adult participant) explained that “. . . If I could go back and then, and I read on it more and then saw the age of eligibility, I would have actually taken it earlier”. Furthermore, other adult participants expressed regrets about their late HPV vaccine receipt in the context of information deficit and economic disempowerment. For example, Telli explained:

I know that the vaccination is supposed to be done before 14 years or so, and I didn’t have this knowledge when I was that young, and [. . .] I wish I had it and probably the resources then to do it

Similarly, Annette conveyed her disappointment:

Oh, I was disappointed about the timing because I should have known this way earlier about it and I later found that I had friends who actually had taken the vaccine almost 10 years ago. . . so I was quite disappointed [. . .] about the awareness and everything

Additionally, Akumaa, who disclosed that she tested positive for HPV, mentioned that “if I had known at that age, I would have [. . .] gone for my vaccine and be protected from this HPV-16”.

Theme 3: Navigating Privilege, Barriers, and Cultural Norms in HPV Vaccine Access

Most participants recognized their HPV vaccine receipt was shaped by socio-economic privileges, including the ability to afford it. They perceived intersections of many barriers, including economic disadvantages, rural residence, and knowledge deficit, as factors contributing to inequitable HPV vaccination. Other participants also talked about conservative social norms about sex and sexual practices as barriers to HPV vaccination.

Social Capital as a Gateway to HPV Vaccination Access

Some participants discussed the intersections of individual privileges, including medical backgrounds, knowledge, and relationships with health professionals at the hospital and how that smoothened their access to HPV vaccination. For example, Telli indicated that someone who “[. . .] previously worked there gave me contacts of someone there [staff at the facility]. Similarly, Emefa conveyed:

. . .I’m in the medical field, so it’s informed my choices already [. . .]. I spoke to my friends, a particular friend who works at the Greater-Accra Regional Hospital and he told me that [. . .] he can help me get the vaccine, he can book . . . So, if I hadn’t known someone there, maybe it would have been a bit more tedious, like going there all the time and I didn’t have their number.

Likewise, Dora (an adult participant), whose sister is a nurse at the hospital, reported receiving favorable treatment because of her sister’s relationship with the staff. She indicated that “I will find it very difficult. I’ll go through a lot of processes and I’ll no more [vaccinate]” if her sister was not working at the hospital. She further explained some of the challenges and how her sister’s relationship with the staff facilitated the vaccination process:

The queue alone is a tension. At times, when I get there, the queue is very long. . . But because of her [sister who is a nurse at the hospital], they will be like am I [Kumi’s] sister? . . . Then I will come and take [vaccinate] and I will go.

Other participants demonstrated awareness of their economic privilege while questioning the practicality of promoting HPV vaccine education among individuals facing economic hardship and daily survival challenges. Akumaa discussed:

When I went for mine, at least I was able to pay, and then I’m like, what of this girl somewhere, you know, who struggles to, let’s say buy even a sanitary pad, how is that person going to get the amount of money to get vaccinated if I should tell the person or I should educate the person about it. . .

Similarly, Araba shed more light on how economic disadvantage and living in low-income neighborhoods can contribute to inequities in HPV vaccination access. She explained:

In those areas, as I said, impoverished areas where they don’t have enough money to even go to the hospital for general or normal checkups, it’s not [. . .] possible for them to just go for a vaccination. That’s why I said some of them can’t pay for anything. They even struggle to get a meal in a day.

Furthermore, other participants explained that HPV vaccination inaccessibility was not only shaped by financial capacity but also access to information and vaccination services. For example, Annette questioned: “I’m like this is something that every woman needs. [. . .] So why is it that expensive? Most Ghanaians cannot afford it. And even people that are working or probably can afford it also do not know about it”. In the same vein, Hardley explained:

With the amount of money, we paid to get it, I doubt that somebody who was already struggling to pay school fees would have actually been able to pay for it. . . it’s very expensive, it’s being gate-keep here in Ghana because apart from Ridge [Greater-Accra Regional Hospital] I don’t think any other hospital does [the] HPV vaccine thing. . .

Stigma and Conservative Socio-Cultural Norms

Some participants’ accounts highlighted three barriers to HPV vaccination, namely (a) cultural prohibitions relating to open discussions about sex and sexual health, (b) adolescent disempowerment and disengagement from health decision-making, and (c) erroneous beliefs about HPV vaccination supported by conservative socio-cultural norms. Emefa explained:

Like how can you talk to your [. . .] Ghanaian parents about sex? . . . It would have been difficult telling my parents that I want to protect myself at that age against a virus that is gotten through sexual intercourse. . . You can’t even ask for money to go for it at that [adolescent] age. They’ll ask you, what are you doing. . ., you’re not even having sex, you’re not doing this, why do you need [it]?

Furthermore, one participant talked about the parental perceptions of adolescents as not being knowledgeable (preconception that adolescents are naive) as a barrier to engaging parents in health discussions. Elsalsa expounded:

Parents have this mentality that you are a child, [. . .], you don’t know anything. So, keep quiet and listen to what I’m saying. Sometimes, it’s good, we actually don’t know anything, but other times, like just so you hear our point of view on it, so that we can explain how to us it feels. [. . .] I prefer not to talk to my parents about any adolescent issues.

Some participants discussed that in Ghanaian societies, the provision of adolescent reproductive health care is associated with promoting sexual promiscuity. Annette spoke more about this:

[. . .] the thing is that [. . .], in the Ghanaian community, people are thinking, okay, you’re giving your children HPV vaccine, so you are exposing them to actually going to have sex and not get the virus, you know, so people feel like almost not giving the vaccine is like a kind of a deterrence [to sex]. . . .Yes, it’s just like contraceptives. [. . .] because it’s all linked to sex.

Likewise, one participant indicated the need to avoid discussions on HPV vaccinations with adolescents to avoid teenage pregnancy. Dora explained:

So, they are schooling and they don’t need any advice. They don’t need to be talking about the vaccines [. . .] to get pregnant at their age. . . like my daughter at this adolescent age like this, she doesn’t need to be lectured about your HPV vaccine or what to get pregnant. [As for me], no!

Discussion

Principal Results

This study explored experiences in accessing HPV vaccination and how intersecting identities contribute to inequities in HPV vaccination access in a privately-funded program in Ghana. Our findings suggest that the current privately funded HPV vaccination program is largely inaccessible to individuals facing economic hardship and structural barriers in Ghana. Inequities in HPV vaccination access were shaped by gender and sex, socio-economic status, and social privilege/special access to healthcare professionals, which align with studies from the United States (Kurani et al., 2022; Truong-Vu, 2021; Xiong et al., 2024) East Africa (Agimas et al., 2024) and a review from low and middle income countries (Marfo et al., 2022). A key finding revealed an attitudinal paradox regarding HPV vaccination timing: adolescents worried about early vaccination, believing it was for older women, whereas older participants lamented their late vaccination due to prior information gaps. Additionally, we uncovered that conservative cultural norms about sex and sexual health and the non-involvement of adolescents in decision-making are barriers to adolescent HPV vaccination. We discuss the details of these findings within the context of the existing literature below.

All participants identified as females or women, highlighting sex and gender inequities in HPV vaccination access in the privately-funded program. Likewise, no male or man was seen at the clinic for HPV vaccination services or making inquiries about the vaccine during observations. This finding is not surprising given the gendered-association of HPV and HPV vaccination (Daley et al., 2017), the influence of early evidence on shaping HPV vaccination policy (Daley et al., 2016; Law & Gustafson, 2017), the social expectation of women’s responsibility to prevent sexually transmitted diseases including HPV (Li et al., 2022), and current international guidelines that continue to prioritize adolescent girls (WHO, 2024). The benefits of HPV vaccination for other sex and genders are evident in recent literature (Powell et al., 2018), which includes protection against rising oropharyngeal cancers in men (Macilwraith et al., 2023) and concomitant positive epidemiological advantages in HPV disease spread among women and females (Dykens et al., 2024; Qendri et al., 2018). In this light, policymakers and stakeholders need to research and evaluate the economic benefits of gender-neutral HPV vaccination programs following the implementation of the upcoming publicly-funded immunization program that will prioritize adolescent girls in Ghana. Appiah et al. (2023) examined the acceptance of HPV vaccination for boys among Ghanaian mothers and found that, despite low awareness, there was a strong willingness to vaccinate their sons. Their study supports raising awareness and educating the public on the benefits of HPV vaccination to ensure equitable access. While socioeconomic challenges and competing health priorities in Ghana may impede gender-neutral vaccination in the forthcoming publicly-funded program, we recommend ongoing education to stakeholders, including parents, adolescents, and healthcare providers, about vaccine benefits and eligibility for non-female sex. This will encourage access and uptake by populations of intended beneficiaries who may be ineligible for the impending publicly-funded program to access HPV vaccines through privately-funded programs. By addressing gender inequities in HPV vaccination, not only can we increase HPV vaccine access among all populations, but we can also reduce the stigma associated with HPV, leading to an overall healthier Ghanaian population (Dykens et al., 2024).

Most of the participants shared that they initially learned about HPV vaccination by coincidence and perceived an information deficit on HPV vaccination among the general Ghanaian population. Similarly, during clinic observations, HPV vaccination services were not listed as part of the available services on the flier in front of the unit. This information gap likely contributed to the paradoxical negative feelings participants experienced regarding the timing of their vaccination. For example, adolescent participants were concerned about receiving the HPV vaccine early, mistakenly believing it was only for older women, while older participants expressed frustration and disappointment over their delayed vaccination due to a lack of early information. This finding is consistent to a qualitative study among young Latina women in Mexico, some of whom blamed themselves for not initiating HPV vaccination sooner (Garcia et al., 2023). These findings highlight the urgent need for health policymakers to invest in continuous public health education on HPV vaccination and leverage accessible media platforms to reach the public as HPV information accessibility has shown a positive influence on vaccination decisions (Llavona-Ortiz et al., 2022; Oketch et al., 2023).

Most participants recognized their intersecting privileged identities and positions (e.g., being a medical professional, having educated parents who are supportive of adolescent reproductive health, having the economic means to afford vaccines, and having privilege/special access to healthcare workers) and linked them to their easy access to HPV vaccination. This finding suggests HPV vaccination is inaccessible to individuals with poor socioeconomic backgrounds, uneducated parents, and non-medical professionals in Ghana, a trend observed in other global contexts (Filakovska Bobakova et al., 2023; Sarmiento-Medina et al., 2024). Unfortunately, until the publicly-funded program begins, HPV vaccination will likely continue to be accessible to only socio-economically and health-literate privileged individuals, due to its high cost and information deficit on its benefits and services. This underscores the need for continuous advocacy for a social justice approach to a national HPV vaccination policy formulation, implementation, and evaluation that advances equitable HPV vaccination outcomes for eligible Ghanaians. Key policy considerations should include, but not be limited to, evaluating vaccine doses that maximize access and population benefits in line with the World Health Organization’s recommendation for a one-dose regimen for adolescents between 9 and 14 years (WHO, 2022b), as well as adopting equitable approaches to vaccine delivery to ensure no target population is left behind.

Although recipients acknowledged the role of their privileged positions in easing access to the HPV vaccine, they reported several obstacles in navigating the vaccination process (e.g., locating HPV vaccination information and services). This finding sheds light on how the privately-funded HPV vaccination program may be inaccessible to some socioeconomically privileged individuals who face disadvantages in other dimensions of inequity. For instance, while the economic ability to afford the vaccine is important, it is not sufficient to ensure access, as this is also influenced by factors such as health literacy, awareness of the vaccine’s benefits, proximity to vaccination services, and parental support for adolescent vaccination, as demonstrated in this study. Importantly, if socioeconomically privileged individuals in this study encountered such challenges, it is likely that those facing socioeconomic hardship and structural barriers experience even greater obstacles to accessing HPV vaccination. Therefore, there is an urgent need for poverty alleviation and socioeconomic empowerment by the Ghanaian government. This can be achieved by maximizing investment in formal education, creating employment opportunities with livable wages, equitably distributing health infrastructure across urban and rural areas, and prioritizing preventive and promotive health over reactive disease treatment (American Public Health Association, 2022; Filmer et al., 2021). Such measures will shift public focus from survival and acute care-seeking to health promotion and disease prevention behaviors, including HPV vaccination. Additionally, we recommend that stakeholders develop and implement reliable, scientifically grounded, and culturally tailored messaging strategies to educate the Ghanaian population about HPV vaccination and available services.

Some participants highlighted conservative cultural norms, which silence open discussions about sex, sexuality, and sexual health as a key barrier to adolescent-parent engagement about HPV vaccination, consistent with a Mexican (Lechuga et al., 2020) and an Ethiopian study (Munea et al., 2022). Yet, it is noteworthy that all adolescent study participants indicated a marked influence of their Ghanaian elite parents (e.g., university lecturer, executive manager, and lawyer) on their HPV vaccination knowledge and decisions, highlighting the critical roles of parents in adolescent HPV vaccination decisions (Balogun & Omotade, 2022; Derbie et al., 2023; Krawczyk et al., 2015; Ogilvie et al., 2010; Smolarczyk et al., 2022). This positive parental role in HPV vaccination decisions reported by adolescent participants emphasizes the significance of targeting parents together with their adolescent children as key stakeholders of HPV educational campaigns before and after the national publicly-funded vaccination roll-out. Such HPV educational approaches will enlighten parents on HPV benefits while demystifying erroneous beliefs that the vaccine promotes sexual promiscuity and early pregnancy. In the same vein, adolescent children will appreciate the benefits of early HPV vaccination, understand post-vaccination expectations, dissociate perceptions of HPV vaccination as older women’s health interventions, and be empowered to initiate conversations about reproductive health problems and service benefits with their parents.

Strengths and Limitations

This study’s strength lies in its use of a qualitative case study design, which enabled us to explore HPV vaccination accessibility within the current privately-funded program at the Greater Accra Regional Hospital through multiple methods. Another strength is the application of intersectionality theory to understand how intersecting identities contribute to HPV vaccination inequities in this context. Although we aimed to recruit a diverse group of participants, the sample ultimately consisted only of relatively socioeconomically privileged girls and women who could afford the high-cost HPV vaccine. This reflects systemic inequities in access, where economic constraints, geographic location, and other structural barriers limit vaccination opportunities for marginalized populations. Consequently, the experiences and perspectives reflected in this study may not fully represent those of individuals facing greater social and economic disadvantage. Future research should prioritize including these underrepresented groups to deepen understanding of barriers and facilitators to HPV vaccination within more marginalized communities. However, our approach aligns with the relational principle of intersectionality (Hill Collins, 2002), which emphasizes that systems of privilege and disadvantage are interconnected and mutually co-construct one another. This allowed us to analyze HPV vaccination inequities from the perspectives of socioeconomically privileged individuals. Furthermore, this represents a strength of the study, as it offers a novel application of intersectionality within the Ghanaian context. It provides valuable insight into how intersecting identities shape access to HPV vaccination without reducing the analysis to fixed identity categories such as “socioeconomically privileged” or “systemically disadvantaged” (Fehrenbacher & Patel, 2020). Although we did not interview parents, the accounts of some adult participants included perspectives on HPV vaccination for their children, further enriching the intersectional analysis.

Conclusions

In line with intersectionality’s focus on health equity and social justice, this study underscores the urgent need for an inclusive, publicly funded HPV vaccination program in Ghana that prioritizes equitable access for socioeconomically disadvantaged populations. Addressing structural barriers and conservative sociocultural norms about reproductive and sexual health will require targeted education for stakeholders and culturally sensitive community engagement. Furthermore, broader investments in poverty alleviation and socioeconomic empowerment are essential to shift health priorities toward preventive care like HPV vaccination. These efforts will be critical to reducing inequities and improving cervical cancer prevention in Ghana.

Supplemental Material

sj-docx-1-gqn-10.1177_23333936251391556 – Supplemental material for “This Is Something Every Woman Needs. . .So Why Is It That Expensive?”: Examining Privileges and Inequities in Access to a Privately Funded HPV Vaccination Program in Ghana

Supplemental material, sj-docx-1-gqn-10.1177_23333936251391556 for “This Is Something Every Woman Needs. . .So Why Is It That Expensive?”: Examining Privileges and Inequities in Access to a Privately Funded HPV Vaccination Program in Ghana by Emmanuel A. Marfo, Charles A. Adjei, Bukola O. Salami and Shannon E. MacDonald in Global Qualitative Nursing Research