This prospective FACT cohort highlights the persistent gap in awareness of HPV, its vaccine uptake, and screening in Nigeria, while demonstrating that targeted sensitisation can drive measurable improvements. Table 1 shows the socio-demographic characteristics of mothers and adolescents enrolled in the FACT study. At baseline, as shown in Table 2, only one-third of mothers and less than 2% of adolescents had heard of HPV, and vaccine awareness was even lower (10.9% of mothers; 0.3% of adolescents). Similarly, in 2020, HPV knowledge and vaccine awareness were recorded as < 3% and 0.5% respectively, in secondary school girls by Ezeanochie and Olasimbo [27]. While the findings in Figure 1 align with prior regional studies in SSA that describe similarly low baseline knowledge of HPV and the vaccine among both adults and adolescents [8,9], few studies have longitudinally tracked HPV awareness and action in mother-adolescent dyads during a national immunisation rollout.

Following the structured sensitisation introduced in April 2024 through the FACT study to stimulate awareness and action for both screening and vaccine uptake among mothers and adolescents, respectively, by leveraging the free, national HPV vaccine rollout. HPV awareness among mothers increased from 34.5 % at baseline to 64.4 % by the 12-month visit (p < 0.0001) as depicted in Figure 2, and vaccine awareness more than doubled (10.9 % to 27.6 %, p = 0.023). Cervical screening showed a similar pattern (Figure 3), while detailed proportions were provided in Table 3. VIA uptake rose from 35.6 % at the baseline to 49.7 % by the 12-month visit (p < 0.0001), whereas PAP smear rates remained static at ≈ 10 %. This aligns with WHO recommendations that prioritise VIA as a pragmatic first-line strategy in resource-limited settings and reflects the greater availability and immediate results advantage of VIA over cytology [28]. Nevertheless, overall screening coverage remains sub-optimal given Nigeria’s high cervical cancer burden [2,5].

Adolescent awareness also improved, albeit from a very low base, reaching 19% for HPV and 12.8% for the vaccine by the final visit. Vaccine uptake rose significantly from 0% at baseline to 3.4% by the 12-month visit (p < 0.0001), as observed in Table 4. The timing and magnitude of these gains (Figure 4) suggest that repeated community engagement and education were key drivers, consistent with evidence that structured outreach and school- or clinic-based education significantly improve HPV knowledge, screening, and vaccine acceptance in sub-Saharan Africa [1,18]. Study findings suggest that low-cost, embedded sensitisation in an HIV cohort can leverage national vaccine rollouts.

In Table 5, the most common reasons mothers cited for not screening were lack of symptoms (“haven’t had any problems,” > 60%) and absence of a provider recommendation (≈ 20 %). Our studies showed that healthcare provider endorsement was prominent both qualitatively and quantitatively and is among the strongest predictors of screening in low- and middle-income countries. These findings underscore missed opportunities in routine clinical encounters [14,17]. These results have immediate policy relevance as Nigeria scales up national HPV vaccination [11].

The absence of a significant association between HPV knowledge and sexual practices among mothers in Figure 5, even after further stratification by HIV status as shown in Figure 6, aligns with previous studies suggesting that knowledge acquisition alone does not necessarily translate into behavioural change [29]. While educational interventions improve understanding of HPV transmission and prevention, their impact on modifying intimate behaviours may be limited without accompanying strategies that address barriers to safer practices [30]. These findings therefore support the integration of behavioural and psychosocial components such as risk perception and supportive frameworks within HPV education programs targeted at mothers and other adult populations.

Qualitatively, participants’ responses show a gap between general awareness and specific knowledge, for example, that HPV causes cervical cancer, the vaccine is most effective at ages 9-14, or that screening can help early detection and prevent spread [1]. This pattern of reasonable surface awareness but poor depth of knowledge that limits preventive action has been reported elsewhere in Nigeria and the region. Studies have documented low detailed knowledge of HPV, cervical cancer, and prevention despite some awareness campaigns, and link poor knowledge to lower screening and vaccine uptake [31,32].

Many mothers expressed beliefs that they or their family are not susceptible to cancer or that screening is unnecessary in the absence of symptoms. Such misconceptions, including the idea that cervical cancer is not relevant unless symptoms are present, reduce preventive screening behaviour. Similar findings in Nigeria [33] and sub-Saharan Africa [30] have shown that low perceived susceptibility and erroneous beliefs undermine uptake of screening and vaccination. Fear about fertility effects, population control conspiracies, and memories of adverse events from other vaccine drives were prominent. These themes echo wider findings that vaccine mistrust, amplified by social media and pandemic-era conspiracy narratives, contribute to hesitancy for HPV vaccination in LMICs, including Nigeria, where parents may fear infertility or hidden agendas [30,35]. Systematic and qualitative reviews link conspiracy beliefs and mistrust to reduced vaccine confidence [14,37].

Quotes indicate that some women were told to “go and get tested” without a clear explanation of what the test was for or how HPV is transmitted. Poor provider communication and missed opportunities for education are common barriers identified; health care practitioners sometimes fail to explain the link between HPV and cancer or to counsel on prevention, leaving health seekers uncertain about the purpose and benefit of screening/vaccination [30,34]. Even when interest exists, participants asked practical questions about location, cost, turnaround time, and benefits. Thus, improving provider-patient communication and using clinic visits as teachable moments is recommended. Studies from Nigeria show that logistical barriers such as uncertainty about where services are offered, perceived or real costs, and convenience, meaningfully reduce uptake and must be addressed alongside information campaigns [33,34].

A notable strength of the FACT study was its integration into the HOMINY prospective cohort midway through implementation. Embedding FACT during three of the four scheduled clinical visits enabled the collection of detailed longitudinal quantitative data on sociodemographic factors, cervical screening, and vaccination status using standardised, interviewer-administered questionnaires to assess the impact. The qualitative component of the intervention sensitisation on HPV knowledge, screening, and vaccination provided a platform to evaluate participants’ reactions, learning, behavioural change, and outcomes.

Qualitative insights were strengthened by quantitative trends, allowing triangulation of findings and a nuanced understanding of the intervention’s impact over time. The convergence of these data builds confidence that the observed changes reflect genuine community-level behavioural shifts that translate awareness into action. Implementing FACT at this strategic midpoint enabled the team to measure baseline knowledge and behaviours, deliver targeted education just before Nigeria’s second-phase HPV vaccine rollout, and assess both immediate and longer-term effects on HPV knowledge and vaccine awareness in participant dyads, uptake among adolescents, as well as HPV screening among mothers.

However, findings rely on self-reported awareness and screening history, which may be affected by recall or social desirability bias. The study population may not be fully representative of all Nigerian communities, and generalisability is uncertain. Additionally, some subgroup analyses were underpowered. A much larger cohort across geopolitical zones in Nigeria will provide greater coverage and assessment.

To translate rising awareness into action, programmes should harness the channels that adolescents and their families already trust and use. Social media platforms and chatting apps popular with young people can host quizzes, short videos, and personal testimonials that dispel myths and reduce stigma around HPV vaccination and screening. Training peer educators in schools and adolescent clubs to lead debates, run interactive sessions, and share accurate information will further normalise preventive behaviours. At the same time, maternal influence can be reinforced by embedding HPV counseling and vaccination reminders into antenatal, postnatal, and routine child-immunisation visits, so mothers receive clear guidance on their own screening needs and their children’s eligibility for vaccination. Women’s associations, faith-based groups, and neighborhood meetings can amplify these messages, while outreach should explicitly include boys, highlighting that HPV is also a cause of oropharyngeal and anogenital cancer and that they, too, are susceptible and need vaccination.

Parallel efforts must focus on expanding accessible screening and treatment services. Training and equipping midwives, nurses, and community health workers to perform VIA and provide immediate treatment can rapidly extend coverage to underserved areas while gradually building laboratory capacity for HPV detection and cytology. This task-shifting approach brings preventive care closer to households, reducing travel barriers and increasing early detection rates. Integrating these clinical services with the community-driven education strategies creates a comprehensive, sustainable framework that protects women, men, boys, and girls from HPV-related cancers.