Rapid Development of a Theory-Based Targeted Intervention and Communication Plan for HPV Vaccine Introduction in Kosovo Using the Behaviour Change Wheel Model

  1. Florie Miftari Basholli
  2. Edita Haxhiu
  3. Isme Humolli
  4. Merita Berisha
  5. Siff Malue Nielsen
  6. Sahil Khan Warsi

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Abstract

Background: Human papillomavirus (HPV) infection is the leading cause of cervical cancer, which presents a significant health burden in low- and middle-income settings such as Kosovo†, where it is the second leading cause of death among women. HPV vaccines are highly effective and integral to global cervical cancer elimination efforts. In 2024, Kosovo† introduced the HPV vaccine into its immunisation schedule via a school-based program targeting sixth-grade girls. Rapid, theory-based insights supported development of a tailored communication and intervention plan ahead of the introduction. Methods: Over a two-week period, qualitative research was conducted with 102 participants, including healthcare professionals, parents, girls in the target age group, school staff, and community influencers. Data collection, analysis, and intervention development were carried out using the Behaviour Change Wheel (BCW) model, underpinned by the Capability, Opportunity, and Motivation for Behaviour change (COM-B) theoretical framework. Results: Trust in school-based immunisation and healthcare professionals emerged as key drivers, while a predominance of capability- and physical-opportunity-related barriers across target groups underscored the need for targeted communication and capacity-building efforts for all stakeholders. Using the BCW model, communication and intervention activities were developed for implementation by partners. Conclusions: Using rapid insight research grounded in the BCW model enabled the timely identification of behavioural drivers and barriers to HPV vaccine acceptance and supported development of a targeted intervention plan. The findings echoed global research on HPV vaccine introduction, highlighting context-specific needs and enablers and contributing to a successful rollout marked by high uptake within the first six months.

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  1. PREreview

    This Zenodo record is a permanently preserved version of a Structured PREreview. You can view the complete PREreview at https://prereview.org/reviews/17153354.

    Does the introduction explain the objective of the research presented in the preprint? Yes
    Are the methods well-suited for this research? Somewhat appropriate 1. The study demonstrates commendable methodological rigor and clear real-world relevance, particularly in its rapid implementation with a sizable sample (102 participants via FGDs/IDIs). However, the two-week timeframe appears quite compressed, and it is not entirely clear how thematic saturation was determined within this period. While the rapid approach is innovative for time-sensitive policy work, providing more detail on how saturation was assessed would strengthen confidence in the findings. 2. The participants were not told about HPV beforehand is concerning. Justification and debriefing details of this would be essential in ethical considerations
    Are the conclusions supported by the data? Highly supported The study demonstrates how rapid qualitative methods, framed within the BCW/COM-B model, informed the development of an intervention and communication plan for the introduction of the HPV vaccine. The association between the identified barriers (e.g., knowledge and skills gaps) and the proposed interventions (education, modelling, environmental restructuring) is clearly stated. Also, the reported outcomes of high uptake within the first 6 months from the tailored interventions provide evidence of the intervention's importance, making it a model for other LMICs However, the two-week timeframe raises questions about the depth of qualitative saturation, and the conclusions might overstate the methodological strength without a clearer justification of how this was achieved. Acknowledging this limitation more explicitly would strengthen the credibility of the conclusion. Overall, the study does fill an important gap in vaccine hesitancy research in LMIC contexts and demonstrates how BCW/COM-B can be applied to design contextually relevant interventions with measurable results.
    Are the data presentations, including visualizations, well-suited to represent the data? Highly appropriate and clear
    How clearly do the authors discuss, explain, and interpret their findings and potential next steps for the research? Somewhat clearly 1. They could add more measuring themes, like the number of participants in each result, to demonstrate a more quantitative analogy. This will provide more context and make the comparison more understandable for the reader or audience 2. No numeric coverage figures provided despite claiming "high uptake." Revise Abstract with sample details and uptake numbers 3. Clarify demographics and representativeness (minorities, out-of-school girls). 4. Add demographics table with participant characteristics 5. Describe the coding/analysis process and validity checks that will bring more reliability to the work. 6. Include a mapping table showing barriers and interventions
    Is the preprint likely to advance academic knowledge? Highly likely The methodological innovation and policy relevance make it a strong candidate for journals like Vaccine or Implementation Science. Also, the intervention plan's implementation led to tangible results (high uptake in the first 6 months), making it an impactful model for other LMICs.
    Would it benefit from language editing? No
    Would you recommend this preprint to others? Yes, but it needs to be improved - Expand limitations (e.g., generalizability, bias) - Add specific policy implications (e.g., Integrate BCW into national vaccine strategies). - Add a subsection on participant recruitment to clarify the sampling strategies across target groups (random vs. purposive). This addition enhances transparency, addresses potential concerns about representativeness, and strengthens the methodological rigor of the study.
    Is it ready for attention from an editor, publisher or broader audience? Yes, after minor changes All are indicated in the previous question Formatting of the document would also be essential if considered and needs focus.

    Competing interests

    The authors declare that they have no competing interests.

  2. Version published to 10.3390/vaccines13080848
  3. Version published to 10.20944/preprints202507.0228.v1