Abstract
<title>Abstract</title> <p>Cervical cancer, predominantly caused by Human Papillomavirus (HPV), remains the fourth most common cancer in women globally, with over 90% of deaths occurring in low- and middle-income countries. School Health and Nutrition Supervisors (SHNS) are the frontline school health cadre whose advocacy quality directly influences HPV vaccination uptake, and their knowledge and the adequacy of health system training targeting them is largely unexamined. This cross-sectional census survey used a validated structured self-administered questionnaire to assess HPV vaccination knowledge, perceptions and beliefs among all 58 actively deployed SHNS across 21 Union Councils of Bahawalpur District, South Punjab, Pakistan (September 2025 to April 2026). Respondents were predominantly male (69.0%), above 40 years of age (79.3%) and held postgraduate qualifications (98.3%). While 96.6% correctly identified the vaccination target age group and 82.8% recognised pre-debut vaccine efficacy, 55.2% harboured the systemic misconception that HPV vaccination provides 100% protection against cervical cancer — a belief most plausibly attributable to flawed or incomplete training content rather than individual inattentiveness, given that 82.8% receive training updates at least annually. Only 37.9% knew the correct two-dose schedule and 41.4% recognised the continuing necessity of post-vaccination cervical cancer screening. All 58 supervisors (100%) had recommended HPV vaccination in the previous 12 months. Education, gender, school type and geographic location were significant predictors of knowledge. These findings demonstrate that a motivated, well-educated workforce is being systematically under-informed by inadequate training content, with direct implications for the quality and clinical accuracy of vaccine promotion delivered to parents and students. Urgent reform of HPV training content, school-level communication protocols and locally adapted Urdu-language materials is required.</p>