A Systematic Review of the Barriers to Implementing Human Papillomavirus Vaccination Programs in Low- and Middle-Income Countries in the Asia-Pacific

"Programs must be tailored to fit the challenges and cultural priorities of each country."

The World Health Organization (WHO) recommends including human papillomavirus (HPV) vaccination in national immunisation programmes, especially in countries where cervical cancer is a public health problem. HPV-related diseases disproportionately impact low- and middle-income countries (LMICs). This systematic review examined the literature on barriers to introduction, implementation, and/or sustainability of HPV vaccination programmes in LMICs in the Asia-Pacific region (AP-LMICs).

Forty-six eligible articles were included in the review, which covered the period 2010-2019. They included 14 systematic reviews, 6 cohort, 15 analytic cross-sectional, and 11 qualitative studies. Barriers were diverse and were classified into four levels:

• Government level: Prevailing themes were lack of funding (19 article citations), resource allocation (18), and political support for HPV screening and prevention (7). For example, the Philippines has inadequate political support for the HPV vaccination programme - support that is necessary to encourage prioritisation of HPV and to initiate collaboration among stakeholders.
• Healthcare provider (HCP) level: Lack of awareness of HPV and HPV vaccination among HCPs (26 citations), unavailability and/or poor accessibility of healthcare establishments (16) and practitioners (4), and lack of recommendations of physicians with regard to HPV prevention (7) were the prevailing themes. For example, a lack of communication between HCPs and young women or parents about HPV vaccination was seen as a factor in low uptake of HPV vaccine in one study. "Involvement of community health workers and local leaders increases vaccination acceptance and uptake within the community..."
• Society level: Level of literacy (11 citations), health literacy (11), culture (11), religion (5), and English literacy (2) were the prevailing themes. For example, cultural norms may hinder awareness, especially where discussion of sexual behaviour is considered taboo. Incorporating health literacy in the educational curriculum or providing educational activities about health and diseases could help increase awareness regarding HPV and HPV-related disease prevention. Workshops, pamphlets, and demonstrations could be used not only to raise awareness on the part of, improve the attitudes of, not only students but also their parents regarding HPV and HPV vaccines. Where adult literacy rate is low, such as in Papua New Guinea, Bhutan, and Nepal, health education strategies must overcome literacy and language barriers and be made accessible to the general public.
• Individual level: Prevailing themes included: personal perception (24 citations), in terms of its safety, efficacy, and cost, and of HPV vaccination and vaccinations in general; individual health-seeking behaviour based on the awareness of personal health and diseases (20); knowledge of HPV as a disease (7); and individual approaches to accessing quality medical care (4). For example, a major reason for limited vaccine uptake is its cost, as well as a perceived low risk of acquiring HPV and HPV-related disease, and thus a high cost-benefit ratio.

In short, this review found that barriers to successful implementation of HPV vaccination programmes are diverse and interrelated, and they differ among AP-LMICs. Thus, policymakers will need to evaluate the relative importance of these barriers in their own contexts in order to draft an effective dissemination and implementation strategy.

In conclusion: "Leadership, advocacy, and intersectoral partnership are essential to sufficiently address the issue of HPV vaccine implementation....Ultimately, financial barriers from both the providers' and the recipients' sides need to be overcome."