Barriers to and Facilitators for Accessing HPV Vaccination in Migrant and Refugee Populations: A Systematic Review

"It is necessary to take all of these determinants into account when developing health promotion strategies and prevention plans to leave no one behind and guarantee adequate levels of healthcare to everyone."

A variety of elements can contribute to low vaccination rates and hesitancy to get vaccinated among certain refugee and migrant groups. The decision to accept vaccines is often deeply embedded in the social and historical backdrop, shaped by the individual's assessment of risk in addition to specific challenges concerning awareness and access to vaccines for some refugee and migrant groups.  The objective of this paper is to evaluate barriers to and facilitators for accessing human papillomavirus (HPV) vaccination in migrant and refugee populations. HPV is the most prevalent sexually transmitted infection (STI) globally and a primary cause of cervical cancer.

A systematic review of the existing peer-reviewed academic literature was conducted according to the PRISMA 2020 guidelines, leading the researchers to examine 34 studies to evaluate HPV vaccination rates in these populations and to identify factors acting as barriers or facilitators. Seventeen of these studies included quantitative data on the adherence to vaccination; the remaining 17 articles were qualitative studies.

From the selected studies, the following data emerged regarding the adherence to HPV vaccination: The average adherence pooled rate was 34.5%; stratifying by sex, the average adherence was 44.4% in females pooled from multiple studies who had completed the vaccination schedule, while for 6 studies, which included females who had not completed the pooled rate, it was 17.4%. One study investigated vaccine adherence in men, with a percentage of adherence to the complete schedule of 0.6%. Based on data from two studies, however, 3% was the pooled rate for males who did not complete the entire vaccination cycle.

As shown in Table 3 in the paper, some barriers have been highlighted in several studies; for example, "lack of health knowledge/literacy; lack of promotion programs; lack of motivation" occurred in 20 studies (58.8%). "Lack of trust in health workers; lack of regular health check-ups" and "low socio-economic level" were recurring barriers in 9 (26.5%) and 12 (35.3%) studies, respectively. In 5 studies (14.7%), "perception of vaccine-related risks" was highlighted as an obstacle. One study reported parents' hesitancy toward vaccinating their sons, though aware of the risk of cervical carcinoma related to HPV infection, as they could not understand "how does that have to do with boys?". This element shows the importance of a complete health education delivered by health professionals.

In some studies, the participants expressed their curiosity about the HPV vaccine and its characteristics. In these studies, people suggested ways to provide such information - for instance, educational workshops to raise awareness about health topics among the youth or information given by the provider, in both oral and written form, so people better retain the acquired knowledge. Others preferred to receive health information through digital media. In any case, people seemed to express the need for a more user-friendly approach.

Indeed, the lack of knowledge appeared to be attributable to the lack of official information by national or local health authorities or recommendations by professionals. Some studies also highlighted how people would appreciate receiving phone calls, text messages, or letters from the vaccination providers as a means to promote vaccine uptake or as reminders about scheduled appointments. Participants of some studies underlined their need to interact with health professionals who spoke the same language as a facilitator for building trust, to deliver educational messages and spread awareness, and in general to facilitate better access to health care.

Throughout several studies, a difference emerged in vaccination uptakes between locals and migrant and refugee people. In some cases, the lack of knowledge about the vaccine among these population groups was attributable to the unavailability of the vaccine in their country of origin.

Another determinant of low vaccination uptake was a lack of family support; women reported they had to take care of their children's health without their husbands' help, while dealing with other family issues or their own job. Some women underlined the importance of their husbands' opinion on their children receiving vaccinations. In some studies, it emerged that discussing sex was considered unacceptable, and parents declared not being willing to vaccinate their children, especially girls, because it would promote a promiscuous sexual attitude.

On the other hand, the most common facilitator appeared to be "adequate communication between patients and health workers; regular access to health services or a specific type of doctor (general practitioner (GP), pediatrician or other specialists)", highlighted in 15 articles (44.1%) as a relevant factor encouraging vaccination acceptance and adherence. The second most common facilitator, recurring in 11 studies (32.3%), was "increasing awareness of prevention strategies; people empowerment; increasing health literacy; information or promotion programs".

In short, the adaptation process to the host community pushes migrants and refugees to prioritise the search for better housing, working, and living conditions, putting aside their own health. However, the factor that appeared to be reported the most was health literacy: A lack of information on the risks of STIs, on ways to prevent them, and eventually on the benefits of adhering to prevention programmes contributes to low vaccine acceptance.

The researchers close by recommending:

• Building trust in health services and healthcare personnel to provide quality of care and give people the possibility to make proper decisions regarding their own health;
• Educating healthcare professionals to be aware that, when interacting with migrant and refugee populations, cultural factors may intervene that hinder access to preventive measures;
• Including interpreters, cultural mediators, and multi-language communication tools and media to support engagement with people with a migratory background in light of the fact that language barriers often limit trust-building mechanisms and affect the capability to receive complete and clear information.

In conclusion: "HPV vaccination rates can be improved only by trying to address the specific challenges in each country, at the structural, cultural, and economic level. This is why multi-sectoral interventions are needed that are tailored to the community and culturally and linguistically appropriate."

Full list of authors, with institutional affiliations: Davide Graci, University of Palermo; Nicolò Piazza, University of Palermo; Salvatore Ardagna, University of Palermo; Alessandra Casuccio, University of Palermo; Anton Drobov, Masaryk University; Federica Geraci, University of Palermo; Angelo Immordino, University of Palermo; Alessandra Pirrello, University of Palermo; Vincenzo Restivo, University Kore of Enna; Riccardo Rumbo, University of Palermo; Rosalba Stefano, University of Palermo; Roberta Virone, University of Palermo; Elena Zarcone, University of Palermo; Palmira Immordino, University of Palermo and Università degli Studi di Palermo