Nurses' and Teachers' Perceived Barriers and Facilitators to the Uptake of the Human Papilloma Virus (HPV) Vaccination Program in Iquitos, Peru: A Qualitative Study

"There is a need for community education programs, for a revision of the process of obtaining parental consent, for improved communication between professionals and for involvement of grassroots staff in policy making."

Peru was the first country in South America to introduce a national human papillomavirus (HPV) vaccination programme in 2011. That year, the average coverage was 34.9% in 2011 but fell to 6.4% in 2016. This study, informed by the socio-ecological model (SEM), qualitatively explored vaccination uptake via in-depth interviews with nurses and teachers involved in HPV vaccine delivery in Iquitos, Loreto, Peru, with the hope of gleaning recommendations for strategies that could be used to increase vaccination rates in the country.

Recognising the intertwined relationship between individuals and their environment, the five-level SEM illustrates that public health problems, such as low vaccine uptake, are complex and affected by multiple levels of influence. This model informed data collection, analysis, and interpretation.

Twenty-one interviews (average length 30 minutes) were conducted in 2019 with eleven nurses working in two primary health centres and ten teachers from four public primary schools in the area. All the participants self-identified as "mestizo" (mixed-race), and most (85.7%) were female.

The five themes that emerged from analysis of the interviews were relevant to more than one level of the SEM, and, therefore, the results are presented by inductive theme (with illustrative quotations):

1. Knowledge - At an individual level, there was widespread basic knowledge on HPV and the HPV vaccine amongst all participants. However, all but one participant highlighted the need for more staff training and a desire for more information on the topic. Nurses and teachers also perceived a lack of parental knowledge as a barrier to vaccination. At a community level, participants mentioned the importance of media, the internet, and new technologies as platforms to deliver information and HPV-related education to the public. A large proportion of the sample highlighted the need to run more informative sessions at a national policy level.
2. Acceptance - Most participants thought parental attitudes and beliefs towards the vaccine were positive. Parents who rejected the vaccine reportedly often did so because of fear of side effects. Parental consent was identified as a major factor that can hinder the successful delivery of the programme. At an interpersonal level, participants also characterised the influence of familial customs and religion as a barrier. At a community level, acceptance was a problem among some indigenous groups.
3. Accessibility - Although all participants thought delivering the vaccine in a school setting was a good strategy, various problems associated with accessibility were identified. Migration and school dropout due to family responsibilities can limit a girl's access to the vaccine, and the region's geography and climate can increase the difficulty of reaching all girls who are eligible for vaccination. A few participants mentioned house-to-house campaigns as a strategy to maximise the number of girls who are vaccinated. Others discussed the need for the programme to include boys.
4. Communication - One nurse argued that the way professionals communicated with each other had changed drastically in the last years. She explained that previously, meetings were held regularly between the relevant professionals. Instant messaging via WhatsApp was now the main method of communication. She identified various problems with this. Participants said they don't have access to the centralised student database, and lack of good infrastructure and internet connectivity remains a problem in the region.
5. Resources - Participants complained of staff shortage and requested additional workers. One reported a shortage of vaccinations, and two reported missing vaccination cards, which further complicated follow-up and completion of the dose schedule. At a public policy level, a proposed strategy was having relevant professionals involved in the decision-making process. Some nurses felt their opinion was not valued and that the people in power were not aware of the region's reality and needs.

Some takeaways from these findings:

• Ensuring appropriate knowledge and high vaccine acceptability amongst professionals is key, since provider recommendation has been repeatedly identified as an important factor in HPV vaccine uptake.
• Parents themselves desire more information on the topic to aid decision making, highlighting the need for improved educational and information campaigns. How to best provide the information needs to be further explored. A few participants expressed negative opinions regarding the provision of information leaflets; Loreto has a 6.4% illiteracy rate in people aged 15 and above.
• Evidence suggests that having to sign a consent form generates parental distrust of the vaccine, as this step is not required for other vaccinations. If written consent is sought, research suggests the promise of asking parents to sign the consent form at school enrolment, a moment that was viewed favourably by various participants.
• Certain beliefs regarding the causes of cervical cancer present in the local population (for example, associating it with witchcraft) might make it difficult to shift social norms towards acceptance of the vaccine. Many remote areas do not have access to mass media and the internet and rely on information from either community members or health workers; therefore, it is important to investigate what interventions might be most effective in such groups.
• Given that nurses and teachers have the most hands-on experience, they can provide valuable insight into the health needs of the population and should therefore be included in policymaking processes.

In conclusion: "Future research is needed to identify the most effective strategies to deliver information and to reduce existing knowledge deficits and address concerns."