Communication Strategies to Improve Human Papillomavirus (HPV) Immunisation Uptake among Adolescents in Sub-Saharan Africa: A Systematic Review and Meta-analysis

"As SSA countries move towards the introduction and implementation of HPV vaccination at the national level, strategies that enhance vaccination campaigns and stakeholder engagement are crucial to increase vaccination uptake and completion."

As of 2020, one-third of sub-Saharan Africa (SSA) countries had introduced human papillomavirus (HPV) immunisation in their national schedule, though incidence of cervical cancer, which the HPV vaccine is meant to protect, has been increasing in SSA. Several low- and middle-income countries (LMICs), especially in SSA, are still struggling with poor immunisation uptake, despite the fact that HPV immunisation is freely available in government health facilities. This systematic review and meta-analysis aims to explore the communication strategies adopted to enhance HPV immunisation in SSA and lessons learned in their implementation in terms of influencing acceptability and uptake.

PubMed, Hinari, Cochrane Library, Trip database, CINAHL, Web of Science, Scopus and seven grey resources were searched for publications dated from inception of database through May 2022. The researchers included observational studies addressing communication strategies for HPV immunisation uptake. Of the 22 studies included, 4 were conducted in Nigeria, 6 were from South Africa, 3 werefrom Kenya, 2 were from Uganda, and there was 1 study each from Cameroon, Mali, and Tanzania. Four studies were conducted in various countries.

The vaccine uptake rates ranged from 31.1% in Kenya to 99.7% in South Africa, depending on the study design, population prioritised, and communication approach adopted.

Subgroup analysis showed that based on the purpose of the intervention, communication purpose to facilitate decision-making achieved 100% (95% confidence interval (CI) 0.99% to 1.00%) uptake, followed by communication purpose to enable communication, which achieved 92% (95% CI 0.92% to 0.92%) uptake rates. Communication intervention to inform and educate achieved 90% (95% CI 0.90% to 0.90%).

Foucsing on both healthcare workers and community leaders with the communication intervention achieved 95% uptake (95% CI 0.91% to 0.98%), while teachers and school boards achieved 92% uptake (95% CI 0.84% to 1.01%). Targeting policymakers achieved 86% uptake (95% CI 0.78% to 0.93%).

Based on the method of communication intervention delivery, use of training achieved an uptake rate of 85% (95% CI 0.84% to 0.87%); similarly, drama and dance achieved 85% (95% CI 0.84% to 0.86%). Use of information, education, and communication (IEC) materials achieved 82% (95% CI 0.78% to 0.87%).

Vaccine adherence and completion was reported by six studies. The completion rates ranged from 60.9% in Cameroon, where the communication channels used included community meetings, informational posters, flyers, television, radio, and newspapers, to 97.8% in South Africa, where intensive communication and education of all stakeholders were done prior to the initiation of the vaccination project. In addition to the community and religious leaders, teachers and educators, healthcare workers, school management boards. and policymakers involved in the latter study, the other stakeholders included according to other studies are: the Department of Health and the Department of Education, parents, learners, educators, healthcare workers, community leaders, and the media. The stakeholders were trained and used to cascade the information down to reach the parents of the adolescent girls and the girls themselves; they also endorsed and advocated for the vaccination activities.

Only one before-and-after study had a comparison system where the baseline data were compared with the end-line data. This population-based study conducted in southeast Nigeria among women and their daughters used a house-to-house education intervention. Following the communication intervention, the vaccine uptake rates increased to 33.2% compared with 0.9% at the baseline. Vaccine acceptance also improved compared with the baseline rates.

Key elements from communication interventions reviewed include:

• Inform or educate
  • Successes
    • Interventions led to general support and trust in vaccines.
    • Sensitisation campaigns were effective.
    • There was increased cervical cancer knowledge, awareness, or intent due to educational intervention.
  • Challenges
    • Most of the general population reported fears of potential side effects as barriers to vaccine acceptance.
    • Cervical cancer vaccination was not considered a priority by others.
    • There was negative messaging from media campaigns in print, broadcast, and online.
  • Lessons learned/recommendations
    • Messaging should include more information on the HPV vaccine safety and effectiveness.
    • Information on HPV should focus on the hard-to-reach population and be tailored to the specific population.
    • Community outreach strategies like mass media are effective approaches to disseminate information.
• Facilitate decision-making
  • Successes
    • After receiving basic HPV information, participants were willing to accept HPV immunisation.
    • A prior measles campaign made parents familiar with vaccination.
  • Challenges
    • There was poor promotion due to lack of invitation from consent issued.
    • It could be logistically difficult to obtain informed consent prior to a child's vaccination.
    • Misinformation and rumours led to negative impact on parental consent.
  • Lessons learned/recommendations
    • Parents/caregivers should be provided with an opportunity and means to provide informed consent.
    • Use of community influencers is an important factor in the parent's vaccine decision-making for the child.
• Enhance community ownership
  • Successes
    • Community health volunteers (CHVs) were considered a valuable source of information.
    • These types of interventions led to high awareness and knowledge among parents/guardians.
    • There was reportedly more willingness to vaccinate and recommend vaccination.
    • Partnerships were built through vaccine donation to local organisations and institutions.
    • There was successful community involvement in awareness creation, vaccination announcements, and follow-up of girls for the 3 vaccine sessions.
    • Voluntary financial contribution to cover administrative costs led to increased community involvement and support.
  • Challenges
    • There was vaccine mistrust by community.
    • Pastoral communities practising female genital mutilation (FGM) misunderstood the HPV vaccination information as a government strategy to counter their traditional practice of FGM, leading to community resistance.
    • Misinformation about infertility being associated with the HPV vaccine emerged from a previous tetanus campaign.
    • People had concerns about effectiveness and side effects.
    • Involvement of multiple stakeholders complicated the social mobilisation.
  • Lessons learned/recommendations
    • CHV utilisation is a promising strategy, as CHVs are valued as source of information and mobilisers in the community setting.
    • There is a critical need to provide detailed information on vaccine benefits to avoid misinformation.
    • Extensive social mobilisation is key in improving uptake.
    • There were concerns around HPV vaccine messaging, indicating the focus on reaching girls before their sexual debut would discourage eligible girls who had passed their sexual debut.
    • There is a need for more expanded outreach programmes to address misconceptions and to ensure that adequate information is available.
    • A future programme should explore conformity to local norms.
    • Community-based educational interventions that are specifically focused on gender and context could increase vaccination.
• Provide support
  • Challenges
    • Partners' objection and religious belief lowered vaccine acceptance.
  • Lessons learned/recommendations
    • Tailor promotional messages to the needs of various groups.
• Enable communication
  • Challenges
    • There was difficulty in translating basic cervical cancer information to local terms - for example, "cervix" equivalent does not exist in some local languages.
  • Lessons learned/recommendations
    • Participatory training that uses simple visual materials in an understandable language is an effective strategy.
• Teach skills
  • Successes
    • Use of community health educators led to trust of the local population.
    • There was increased knowledge from peer education.
    • Training of primary health workers builds skills and capacities related to cancer prevention at the community level.
  • Lessons learned/recommendations
    • The use of health educators working in primary healthcare is a sustainable option.
    • Peer education system is an effective strategy.

In conclusion: "HPV vaccine communication is critical in ensuring that the community understands the importance of vaccination. The most effective communication strategies included those which educate the population about the HPV vaccine, facilitate decision-making on vaccine uptake and community ownership of the vaccination process immunisation."