Implementation Strategies Used to Increase Human Papillomavirus Vaccination Uptake by Adolescent Girls in Sub-Saharan Africa: A Scoping Review

"[P]romoting, and tailoring strategies in the use of the HPV vaccine in SSA implies developing tactics specific to the region's circumstances and problems. Addressing issues, such as culturally appropriate communication, scarce resources, inadequate healthcare facilities, and low knowledge is part of this."

Many sub-Saharan Africa (SSA) countries have yet to implement national human papillomavirus (HPV) vaccination programmes and are further challenged by low vaccine uptake in implementing countries. Some identified barriers to HPV vaccine uptake include individual, structural, economic, community/social, and cultural issues, as well as the COVID-19 pandemic. Furthermore, systemic health system constraints occur in many SSA countries, including low levels of community engagement, vaccine communication, and knowledge among various stakeholders. This scoping review aimed to identify implementation strategies used in SSA to increase HPV vaccination uptake for adolescent girls.

The scoping review was guided by Joanna Briggs Institute guidelines for scoping reviews and an a priori protocol and reported based on the Preferred Reporting Items for Systematic Reviews and Metanalysis for Scoping Reviews (PRISMA-ScR). The researchers searched PubMed, EMBASE, CINAHL, Scopus, Google Scholar, and gray literature. They identified strategies as specified in the Expert Recommendation for Implementing Change (ERIC) and reported their importance and feasibility. They retrieved 246 articles, included 28 of these, and identified 63 of the 73 ERIC implementation strategies with 667 individual uses, most of which were highly important and feasible. Publication year ranged from 2011 to 2021.

Some studies indicated reaching out-of-school girls through community sensitisation and active tracing by community healthcare workers. Other studies only focused on school delivery approaches. In some studies, there were multiple locations where girls could access the vaccine, such as from schools and health facilities for out-of-school girls or school girls who missed the vaccine offered at school. In some instances, HPV vaccination delivery was integrated with other health programmes, such as sexual health reproductive education.

The most frequently used discrete strategies included the following, which the researchers comment on in the paper's discussion section:

• Build a coalition and change service sites 86% (24/28). Considering that multiple stakeholders worked together across the different studies (e.g., ministries of health and education, vaccination bodies, non-governmental organisations, and the communities worked together to achieve a common goal of increasing HPV vaccination), understanding the stakeholder landscape and networking during the planning and implementation of HPV vaccination programmes is key to successful implementation.
• Distribute educational materials and conduct educational meetings 82% (23/28). A systematic review on educational intervention and knowledge levels among different stakeholders will be key to understanding the value of education-related interventions in the HPV vaccination space in SSA to change the current landscape.
• Develop educational materials, use mass media, involve patients/relatives and families, promote network weaving, and stage implementation scale up 79% (22/28). General messaging around vaccines improves understanding and increases end-user confidence across multiple stakeholders.
• Access new funding, promote adaptability, and tailor strategies 75% (21/28). A systematic review and meta-analysis on effective communication strategies to increase HPV vaccination uptake among adolescent girls in SSA reported that tailoring communication interventions to specific stakeholders yielded positive results. The review reported that 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.

The researchers suggest that improved reporting of implementation strategies by national programmes is needed to learn lessons from similar contexts, considering that most SSA countries are now planning or are introducing national HPV vaccination programmes. These studies should be well designed with clearly defined strategies for better evaluations and comparisons across studies and settings.

In conclusion: "This scoping review shows that implementation strategies of high feasibility and importance were frequently used, suggesting that some strategies may be cross-cutting, but should be contextualized when planned for use in any region."