Feasibility and acceptability of nationwide HPV vaccine introduction in Senegal: Findings from community-level cross-sectional surveys, 2020

Examining the impact of sex-biased information on health behaviors: a study of HPV vaccination among male college students based on the extended theory of planned behavior

Introduction

Human papillomavirus (HPV) is an exceptionally transmissible virus with a widespread presence that represents a considerable public health concern. Notably, the existing information landscape regarding HPV vaccination tends to favor female perspectives, which may inadvertently neglect the risks associated with HPV infection in men-particularly among male college students, who constitute a vulnerable demographic. To address this gap, effective health communication strategies are essential to encourage vaccination behaviors. This study seeks to extend the Theory of Planned Behavior (TPB) to investigate how sex-biased information influences the HPV vaccination intentions of male college students.

Methods

A survey involving 240 participants was conducted to analyze the correlation between the HPV vaccine information environment and vaccination intentions. Utilizing Structural Equation Modeling (SEM), we assessed both direct and indirect effects that shape this relationship.

Results

Findings reveal that sex-biased HPV vaccination information can have both direct and indirect effects on the vaccination behaviors of male university students. Specifically, attitudes towards the vaccine positively influence the willingness to receive free vaccinations, while subjective norms and perceived behavioral control positively impact the intention to obtain both paid and free vaccinations.

Discussion

This study highlights that the female-oriented focus of HPV vaccination information, which underscores feminine norms, may limit the effectiveness of HPV health education for male college students. Additionally, price considerations have a limiting impact on the favorable attitudes of male university students towards vaccination. Conversely, male-targeted informational campaigns that heighten perceptions of HPV-related risks can diminish price sensitivity regarding vaccines, ultimately fostering increased willingness to vaccinate. The paper concludes by suggesting avenues for future research aimed at developing health communication strategies to enhance HPV vaccination rates among men. Implications and limitations are discussed.

HPV Vaccine Delivery Strategies to Reach Out-of-School Girls in Low- and Middle-Income Countries: A Narrative Review

Background/Objectives: Low- and middle-income countries (LMICs) have the highest global burden of cervical cancer deaths. Human papillomavirus (HPV) vaccination is a key strategy for cervical cancer elimination, and in LMICs, global recommendations to vaccinate girls aged 9-14 years against HPV are generally implemented through school-based immunization platforms. Unfortunately, this strategy risks missing out-of-school (OOS) girls (i.e., girls not enrolled in formal schools). This narrative review maps the literature and synthesizes existing evidence on service delivery strategies for reaching OOS girls with HPV vaccination in LMICs. Methods: Using relevant databases, we conducted a narrative review of published, peer-reviewed literature to map and synthesize the existing evidence on effective service delivery strategies for reaching OOS girls with HPV vaccination in LMICs. Results: The 21 articles identified presented findings on strategies to reach OOS girls, with the most frequently cited strategies being facility-based and community outreach approaches. Authors also described community-based strategies used to identify and enumerate OOS girls, including peer tracing, church outreach initiatives, as well as partnerships with local groups (e.g., civil service organizations) and individuals (e.g., healthcare workers, teachers). The articles discussed barriers at the individual (e.g., lack of parental consent), facility/program delivery (e.g., lack of transportation for vaccines), and community (e.g., distance from homes to vaccination services) levels to HPV vaccine delivery, as well as solutions at the facility/program delivery (e.g., pilot programs) and community (e.g., multi-level partnerships) levels. Conclusions: Additional research is needed to evaluate implementation strategies targeting OOS girls with HPV vaccination. A better understanding of these strategies can provide valuable insights for HPV vaccine policymakers, healthcare providers, and program implementers.

Exploring the complexity of the implementation determinants of human papillomavirus vaccination in Africa through a systems thinking lens: A rapid review

A rapid review was conducted to explore the implementation determinants of human papillomavirus (HPV) vaccination in the World Health Organization African Region and describe their dynamic relationship. PubMed and Google Scholar were searched in October 2023 to find relevant literature. A total of 64 published studies that reported factors affecting HPV vaccination were identified. Analysis of identified factors yielded 74 implementation determinants of HPV vaccination across the five domains of the Consolidated Framework for Implementation Research (CFIR): two (2.70%) were in the innovation domain, seven (9.46%) were in the outer setting domain, 14 (18.92%) were in the inner setting domain, 37 (50%) were in the individual domain and 14 (18.92%) were in the implementation process domain. A causal loop diagram of these implementation determinants revealed four balancing and seven reinforcing loops. Applying systems lens promoted a more holistic understanding of the implementation determinants of HPV vaccination, exposing leverage points for interventions.

Improving HPV Vaccination Uptake Among Adolescents in Low Resource Settings: Sociocultural and Socioeconomic Barriers and Facilitators

Background

Lower- and middle-income countries (LMICs) are disproportionately impacted by human papillomavirus (HPV) and would benefit from implementing the HPV vaccine. In the context of competing health priorities, utilizing scarce domestic infrastructure and human resources for HPV vaccination remains challenging for many LMICs. Given the high benefits of the HPV vaccine, the World Health Organization (WHO) is now encouraging for all countries, particularly LMICs, to introduce HPV vaccines into their routine immunization programs. Understanding the barriers and facilitators to HPV adolescent vaccine programs in LMICs may help strengthen how LMICs implement HPV vaccine programs, in turn, increasing HPV vaccine acceptance, uptake, and coverage.

Objective

To identify and assess barriers and facilitators to implementing adolescent HPV vaccination programs in LMICs.

Methods

This study comprised a review of literature assessing adolescent HPV vaccination in LMICs published after 2020 from a sociocultural perspective.

Results

Overall, the findings showed that LMICs should prioritize increasing HPV vaccine availability and HPV vaccine knowledge, particularly focusing on cancer prevention, as knowledge reduces misinformation and increases vaccine acceptance. Evidence suggests that factors promoting HPV vaccine uptake include fostering low vaccine hesitancy, integrating HPV vaccination as a primary school routine vaccination, and vaccinating both genders. A one-dose HPV vaccine may enable many LMICs to increase vaccine acceptance, uptake, and coverage while controlling financial, infrastructure, and human resource costs.

Conclusion

As HPV is one of the leading causes of death in many LMICs, implementing the HPV vaccine may be highly beneficial. Cohesive national HPV vaccine buy-in and understanding the success and challenges of prior LMIC HPV vaccine implementation is crucial to developing effective, efficient, and sustainable HPV vaccination programs.

Global perspectives of determinants influencing HPV vaccine introduction and scale-up in low- and middle-income countries

Achieving WHO cervical cancer elimination goals will necessitate efforts to increase HPV vaccine access and coverage in low-and-middle-income countries (LMICs). Although LMICs account for the majority of cervical cancer cases globally, scale-up of HPV vaccine programs and progress toward coverage targets in LMICs has been largely insufficient. Understanding the barriers and facilitators that stakeholders face in the introduction and scale-up of HPV vaccination programs will be pivotal in ensuring that LMICs are equipped to optimize the implementation of HPV vaccination programs. This qualitative study interviewed 13 global stakeholders categorized as either academic partners or global immunization partners to ascertain perspectives regarding factors affecting the introduction and scale-up of HPV vaccination programs in LMICs. Global stakeholders were selected as their perspectives have not been as readily highlighted within the literature despite their key role in HPV vaccination programming. The results of this investigation identified upstream (e.g., financial considerations, vaccine prioritization, global supply, capacity and delivery, and vaccine accessibility, equity, and ethics) and downstream (e.g., vaccine acceptability and hesitancy, communications, advocacy, and social mobilization) determinants that impact program introduction and scale-up and confirmed that strong political commitment and governance are significant in garnering support for HPV vaccines. As LMICs introduce HPV vaccines into their national immunization programs and develop plans for scaling up vaccination efforts, strategic approaches to communications and advocacy will also be needed to successfully meet coverage targets.

Correlates of Parental Consent to Human Papillomavirus Vaccine Uptake by Their Adolescent Daughters in ZAMBIA: Application of the Health Belief Model

Parental consent for adolescent human papillomavirus (HPV) vaccine uptake is important; however, refusal is prevalent. Therefore, this study aimed to understand factors associated with parental consent for their adolescent daughter's HPV vaccination. A cross-sectional study was conducted in Lusaka, Zambia, between September and October 2021. We recruited parents from different social settings. The means and standard deviations or median and interquartile ranges were used as appropriate to summarise continuous variables. Simple and multiple logistic regression models were fitted with robust estimation of standard errors. The odds ratios are presented with 95% CI. Mediation analysis was conducted using a generalised structural equation model. The study enrolled 400 parents, mean age 45.7 years [95% CI, 44.3-47.1]. Two hundred and fifteen (53.8%) parents reported consenting to their daughters' HPV vaccination, and their daughters received it. None of the health belief model (HBM) construct scores showed an independent association with parental consent. Higher, compared to lower wealth index (AOR; 2.32, 95% CI: 1.29-4.16), knowing someone with genital warts (AOR = 2.23, 95 CI: 1.04-4.76), cervical cancer screening uptake (AOR = 1.93, 95% CI: 1.03-3.62) were associated with increased odds of parental consent. This study highlights factors influencing parental consent for their daughters' HPV vaccination. Ongoing sensitisation programs are important to improve their decision-making.

Acceptability of an integrated school-based HPV vaccination program within two districts of Tanzania: A qualitative descriptive study

Tanzania has one of the highest cervical cancer incidence and mortality rates in sub-Saharan Africa. The Tanzanian Ministry of Health developed an integrated adolescent health program, HPV-Plus, that combines HPV vaccination with additional health services: nutritional assessments, vision screening, and vaccination for adolescent girls, and education for all genders. This qualitative descriptive study evaluated the acceptability of the HPV-Plus program in two districts in Tanzania. Key informants comprising of adolescent girls, parents, program planners, and program implementers in Njombe and Dar es Salaam Tanzania were interviewed to assess the program acceptability. Transcripts were analyzed using a team-based iterative thematic analysis approach, consisting of both inductive and deductive coding. The Theoretical Framework of Acceptability was used to guide analysis, with themes categorized according to theoretical constructs of intervention coherence, affective attitudes and perceptions, and perceived effectiveness. Overall acceptability of the HPV-Plus program was high among stakeholders. The most salient finding regarding factors that influenced HPV vaccine acceptability was largely related to education and knowledge levels surrounding the HPV, cervical cancer, and HPV vaccines. The educational component of the HPV-Plus program was key in increasing acceptability. Parents reported the lowest acceptability towards the program. This was found to be primarily due to perceptions of not being sufficiently engaged throughout program implementation. Increasing acceptability of HPV vaccination programs among key stakeholders is critical to facilitating vaccine uptake and meeting vaccination coverage targets. Our results demonstrate that the inclusion of a comprehensive education component within the HPV-Plus program was key in facilitating HPV vaccine acceptability amongst stakeholders.