Barriers and facilitators to HPV vaccination: perspectives from Malawian women

Of Money and Men: A Scoping Review to Map Gender Barriers to Immunization Coverage in Low- and Middle-Income Countries

Among the multiple factors impeding equitable childhood immunization coverage in low- and middle-income countries (LMICs), gender barriers stand out as perhaps the most universal. Despite increasing recognition of the importance of gender considerations in immunization programming, there has not yet been a systematic assessment of the evidence on gender barriers to immunization. We conducted a scoping review to fill that gap, identifying 92 articles that described gender barriers to immunization. Studies documented a range of gender influencers across 43 countries in Africa and South Asia. The barrier to immunization coverage most frequently cited in the literature is women's lack of autonomous decision-making. Access to immunization is significantly impacted by women's time poverty; direct costs are also a barrier, particularly when female caregivers rely on family members to cover costs. Challenges with clinic readiness compound female caregiver's time constraints. Some of the most important gender barriers lie outside of the usual purview of immunization programming but other barriers can be addressed with adaptations to vaccination programming. We can only know how important these barriers are with more research that measures the impact of programming on gender barriers to immunization coverage.

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.

Vaccine hesitancy in Malawi: a threat to already-made health gains

Malawi faces a growing concern about vaccine hesitancy. This threatens to undermine significant strides in the fight against infectious diseases in the country. Vaccine hesitancy in Malawi is driven by multiple factors. This short communication discusses the extent of vaccine hesitancy in Malawi and its main drivers according to SAGE's (Strategic Advisory Group of Expert) 3Cs (confidence, complacency and convenience) model of vaccine hesitancy. As an escalating health concern, it is imperative to address it urgently. It is imperative to address it urgently through comprehensive and sustainable awareness campaigns that should aim to increase acceptance and demand for vaccines.

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

Barriers to successful implementation of the human papillomavirus vaccination exist. However, there is limited evidence on implementation strategies in sub-Saharan Africa (SSA). Therefore, this scoping review aimed to identify implementation strategies used in SSA to increase HPV vaccination uptake for adolescent girls. This 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). We searched PubMed, EMBASE, CINAHL, Scopus, Google Scholar, and gray literature. Two independent reviewers screened article titles and abstracts for possible inclusion, reviewed the full text, and extracted data from eligible articles using a structured data charting table. We identified strategies as specified in the Expert Recommendation for Implementing Change (ERIC) and reported their importance and feasibility. We 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. The most frequently used discrete strategies included the following: Build a coalition and change service sites 86% (24/28), distribute educational materials and conduct educational meetings 82% (23/28), develop educational materials, use mass media, involve patients/relatives and families, promote network weaving and stage implementation scale up 79% (22/28), as well as access new funding, promote adaptability, and tailor strategies 75% (21/28). 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.

Barriers and facilitators of HPV vaccination in sub-saharan Africa: a systematic review

BACKGROUND

Human Papilloma Virus (HPV) is the most common sexually transmitted infection worldwide. Globally, both men and women have a 50% risk of being infected at least once in their life. HPV prevalence is among the highest in sub-Saharan Africa (SSA), at an average of 24%. HPV causes different types of cancers, including cervical cancer (CC), which is the leading cause of cancer deaths among women in SSA. HPV-vaccination has been proven to be effective in reducing HPV induced cancers. SSA countries are delayed in reaching the WHO's target of fully vaccinating 90% of girls within the age of 15 by 2030. Our systematic review aims to identify barriers and facilitators of HPV-vaccination in SSA to inform national implementation strategies in the region.

METHODS

This is a mixed method systematic review based on the PRISMA statement and The Joanna Briggs Institute Reviewers' Manual. Search strategies were adapted to each selected database: PubMed/MEDLINE, Livivo, Google Scholar, Science Direct, and African Journals Online for papers published in English, Italian, German, French and Spanish between 1 December 2011 and 31 December 2021. Zotero and Rayyan were the software used for data management. The appraisal was conducted by three independent reviewers.

RESULTS

A total of 20 articles were selected for appraisal from an initial 536 articles. Barriers included: limited health system capacities, socio-economic status, stigma, fear and costs of vaccines, negative experience with vaccinations, COVID-19 pandemic, lack of correct information, health education (HE) and consent. Additionally, we found that boys are scarcely considered for HPV-vaccination by parents and stakeholders. Facilitators included: information and knowledge, policy implementation, positive experience with vaccinations, HE, stakeholders' engagement, women's empowerment, community engagement, seasonality, and target-oriented vaccination campaigns.

CONCLUSIONS

This review synthesizes barriers and facilitators of HPV-vaccinations in SSA. Addressing these can contribute to the implementation of more effective HPV immunization programs targeted at eliminating CC in line with the WHO 90/70/90 strategy.

REGISTRATION AND FUNDING

Protocol ID: CRD42022338609 registered in the International Prospective Register of Systematic Reviews (PROSPERO). Partial funds: German Centre for Infection research (DZIF) project NAMASTE: 8,008,803,819.

Using branded behaviour change communication to create demand for the HPV vaccine among girls in Malawi: An evaluation of Girl Effect's Zathu mini magazine

The HPV vaccine was introduced nationally in Malawi in 2019 and administered to 9-year-old girls. In order to drive uptake of the HPV vaccine Girl Effect utilised their youth brand, Zathu, to deliver messaging on the HPV vaccine. A Zathu 'mini magazine' was created specifically for 9-year-old girls to provide information, prompt household conversations and build empowerment around the HPV vaccine. This evaluation assessed the effectiveness of the Zathu mini magazine against two outcomes: (1) Girls are more informed & motivated to receive the HPV vaccine and (2) Girls talk to their caregivers about the HPV vaccine.A quasi-experimental approach was adopted using both qualitative and quantitative data collection to measure the results against these outcomes. The study found positive correlations between consumption of the Zathu mini magazine and awareness of cervical cancer, and positive attitudes towards the HPV vaccine among girls and parents in the exposed group compared to the non-exposed group. The Zathu mini magazine also encouraged household discussions on the HPV vaccine. Most significantly, consumption of the mini magazine was also positively correlated with uptake of the HPV vaccine among girls. This study highlights the value of girl-centred communications in demand generation for the HPV vaccine. There is potential to learn from and replicate this approach in other comparable settings.

COVID-19 Vaccination in Lower-Middle Income Countries: National Stakeholder Views on Challenges, Barriers, and Potential Solutions

The development of COVID-19 vaccines does not imply the end of the global pandemic as now countries have to purchase enough COVID-19 vaccine doses and work towards their successful rollout. Vaccination across the world has progressed slowly in all, but a few high-income countries (HICs) as governments learn how to vaccinate their entire populations amidst a pandemic. Most low- and middle-income countries (LMICs) have been relying on the COVID-19 Vaccines Global Access (COVAX) Facility to obtain vaccines. COVAX aims to provide these countries with enough doses to vaccinate 20% of their populations. LMICs will likely encounter additional barriers and challenges rolling out vaccines compared HICs despite their significant experience from the Expanded Programme on Immunisation (EPI). This study explores potential barriers that will arise during the COVID-19 vaccine rollout in lower-middle-income countries and how to overcome them. We conducted sixteen semi-structured interviews with national-level stakeholders from Ghana and Bangladesh (eight in each country). Stakeholders included policymakers and immunisation programme experts. Data were analysed using a Framework Analysis technique. Stakeholders believed their country could use existing EPI structures for the COVID-19 vaccine rollout despite existing challenges with the EPI and despite its focus on childhood immunisation rather than vaccinating the entire population over a short period of time. Stakeholders suggested increasing confidence in the vaccine through community influencers and by utilising local government accredited institutions such as the Drug Authorities for vaccine approval. Additional strategies they discussed included training more health providers and recruiting volunteers to increase vaccination speed, expanding government budgets for COVID-19 vaccine purchase and delivery, and exploring other financing opportunities to address in-country vaccine shortages. Stakeholders also believed that LMICs may encounter challenges complying with priority lists. Our findings suggest that COVID-19 vaccination is different from previous vaccination programs, and therefore, policymakers have to expand the EPI structure and also take a systematic and collaborative approach to plan and effectively rollout the vaccines.

Why don't adolescent girls in a rural Uganda district initiate or complete routine 2-dose HPV vaccine series: Perspectives of adolescent girls, their caregivers, healthcare workers, community health workers and teachers

INTRODUCTION

Vaccination with the 2-dose HPV vaccine series among adolescent girls in Uganda remains low after almost 5 years since the vaccine was included into the routine national immunization program and barriers are not well understood.

OBJECTIVE

We explored barriers that prevent eligible girls from initiating or completing the recommended 2-dose HPV vaccine series in Oyam District, Northern Uganda.

METHODS

A qualitative study was conducted in Oyam District, Northern Uganda. Forty interviews were conducted with adolescent girls, their caregivers, Village Health Team Members, health workers and school administrators involved in HPV vaccination. All interviews were audio recorded and transcribed. NVivo version 11 was used for data management and content thematic approach for analysis guided by the Social Ecological Model.

RESULTS

At individual level, low levels of knowledge about the vaccine, girls' frequent mobility between vaccine doses, school absenteeism and drop out, fear of injection pain and discouragement from caregivers or peers were key barriers. At the health facilities level, reported barriers included: few healthcare workers, inadequate knowledge about HPV vaccine, limited social mobilization and community engagement to promote the vaccine, limited availability of the HPV vaccine, unreliable transportation, lack of reminder strategies after the first dose of the vaccine, lack of vaccination strategy for out-of-school girls and un-friendly behaviour of some healthcare workers. Concerns about safety and efficacy of the vaccine, negative religious and cultural beliefs against vaccination, rumors and misconceptions about the vaccine, mistrust in government intentions to introduce the new vaccine targeting girls, busy schedules and the gendered nature of care work were key community level barriers.

CONCLUSION

Our study revealed an interplay of barriers at individual, health facility and community levels, which prevent initiation and completion of HPV vaccination among adolescent girls. Strengthening HIV vaccination programs and ensuring high uptake requires providing appropriate information to the girls plus the community, school and health facility stakeholders; addressing cold chain challenges as well as adequate training of vaccinators to enable them respond to rumors about HPV vaccination.

Stakeholders' Understandings of Human Papillomavirus (HPV) Vaccination in Sub-Saharan Africa: A Rapid Qualitative Systematic Review

Cervical cancer rates in Sub-Saharan Africa (SSA) are amongst the highest worldwide. All three of the Human Papillomavirus (HPV) vaccines (9-valent, quadrivalent and bivalent HPV vaccine) provide primary protection against the most common cancer-causing strains of HPV (types 16 and 18) that are known to cause 70% of cervical cancers. Over the last five years, there has been an increase in Sub-Saharan African countries that have introduced the HPV vaccine. The majority of research has been conducted on supply-side barriers and facilitators to HPV vaccination uptake in SSA, yet little research has been conducted on demand-side or end-user perspectives of, and decisions around, HPV vaccination. In order to complement existing research, and inform current and future HPV vaccination implementation approaches, this qualitative systematic review explored Stakeholders' understandings of HPV vaccination in SSA. This review searched the following databases: Embase (via Scopus), Scopus, MEDLINE (via PubMed), PubMed, EBSCOhost, Academic Search Premier, Africa-Wide Information, CINAHL, PsycARTICLES, PsycINFO, SocINDEX, Web of Science, and the Cochrane Controlled Register of Trials (CENTRAL) and found a total of 259 articles. Thirty-one studies were found eligible for inclusion and were analyzed thematically using Braun and Clarke's methods for conducting a thematic analysis. The quality of included studies was assessed using the Critical Appraisal Skills Programme (CASP) checklist. Three major themes emerged from this analysis; knowledge of HPV vaccination and cervical cancer is intertwined with misinformation; fear has shaped contradictory perceptions about HPV vaccination and gender dynamics are relevant in how stakeholders understand HPV vaccination in SSA.

Health systems constraints and facilitators of human papillomavirus immunization programmes in sub-Saharan Africa: a systematic review

Given the vast investments made in national immunization programmes (NIPs) and the significance of NIPs to public health, it is important to understand what influences the optimal performance of NIPs. It has been established that well-performing NIPs require enabling health systems. However, systematic evidence on how the performance of health systems impacts on NIPs is lacking, especially from sub-Saharan Africa. We conducted a qualitative systematic review to synthesize the available evidence on health systems constraints and facilitators of NIPs in sub-Saharan Africa, using human papillomavirus immunization programmes as a proxy. Fifty-four articles published between 2008 and 2018 were found to be eligible. Data extraction was guided by an analytical model on the interface between NIPs and health systems. A cross-cutting thematic analysis of the extracted data was performed. This systematic review provides evidence necessary for informing ongoing health systems strengthening initiatives in sub-Saharan Africa. There is evidence to suggest that NIPs in sub-Saharan Africa have surmounted significant health systems constraints and have achieved notable public health success. This success can be attributed to strong political endorsement for vaccines, clear governance structures and effective collaboration with global partners. Despite this, significant health systems constraints persist in service delivery, vaccine communication, community engagement, the capacity of the health workforce and sustainable financing. These constraints could derail further progress if not addressed through health systems strengthening efforts. There is a need to expand the research agenda to include the comprehensive evaluation of health systems constraints and facilitators of NIPs within sub-Saharan Africa.

Health system factors influencing uptake of Human Papilloma Virus (HPV) vaccine among adolescent girls 9-15 years in Mbale District, Uganda

Background

Globally, cervical cancer is the fourth most common cancer in women with more than 85% of the burden in developing countries. In Uganda, cervical cancer has shown an increase of 1.8% per annum over the last 20 years. The availability of the Human Papillomavirus (HPV) vaccine presents an opportunity to prevent cervical cancer. Understanding how the health system influences uptake of the vaccine is critical to improve it. This study aimed to assess how the health systems is influencing uptake of HPV vaccine so as to inform policy for vaccine implementation and uptake in Mbale district, Eastern Uganda.

Methods

We conducted a cross sectional study of 407 respondents, selected from 56 villages. Six key informant interviews were conducted with District Health Officials involved in implementation of the HPV vaccine. Quantitative data was analyzed using Stata V.13. Prevalence ratios with their confidence intervals were reported. Qualitative data was audio recorded, transcribed verbatim and analyzed using MAXQDA V.12, using the six steps of thematic analysis developed by Braun and Clarke.

Results

Fifty six (14%) of 407 adolescents self-reported vaccine uptake. 182 (52.3%) of 348 reported lack of awareness about the HPV vaccine as the major reason for not having received it. Receiving vaccines from outreach clinics (p = 0.02), having many options from which to receive the vaccine (p = 0.02), getting an explanation on possible side-effects (p = 0.024), and receiving the vaccine alongside other services (p = 0.024) were positively associated with uptake.

Key informants reported inconsistency in vaccine supply, inadequate training on HPV vaccine, and the lack of a clear target for HPV vaccine coverage as the factors that contribute to low uptake.

Conclusion

We recommend training of health workers to provide adequate information on HPV vaccine, raising awareness of the vaccine in markets, schools, and radio talk shows, and communicating the target to health workers.

Uptake of the HPV vaccine was lower than the Ministry of Health target of 80%. We recommend training of health workers to clearly provide adequate information on HPV vaccine, increasing awareness about the vaccine to the adolescents and increasing access for girls in and out of school.

[Human papillomavirus vaccine receptivity: a systematic reviewReceptividad con respecto a la vacuna contra el virus del papiloma humano: revisión sistemática]

Objetivo.

Caracterizar a receptividade à vacina contra o papilomavírus humano (HPV) e descrever as barreiras e os facilitadores dessa receptividade.

Métodos.

Trata-se de uma revisão sistemática conforme o protocolo PRISMA 2015. Os repositórios MEDLINE e Web of Science foram consultados utilizando combinações dos termos papillomavirus, vaccine, adherence e acceptance para identificar artigos publicados de 2006 a 2017. Foram incluídos artigos originais em qualquer idioma e excluídos artigos duplicados. Foram analisadas identificação do artigo, tipificação metodológica e caracterização da amostra. A receptividade foi caracterizada em termos de aceitação e adesão.

Resultados.

Foram identificados 212 artigos, sendo 10 selecionados para análise. A maioria dos estudos evidenciou receptividade favorável, porém heterogênea, havendo maior aceitação do que adesão, principalmente por adolescentes do sexo feminino. Foram identificados 11 facilitadores e nove barreiras à receptividade, com destaque para conhecimento relativo ao tema e padrão de comportamento individual frente ao problema. Observou-se a inexistência de um método padronizado que avalie a temática e a imprecisão dos conceitos associados a aceitação e adesão. Diante disso, o estudo propôs conceitos de aceitação (intenção voluntária de receber uma vacina ou concordar que a mesma representa uma boa estratégia preventiva) e adesão (ato de iniciar a vacinação e completar o esquema).

Conclusões.

Novos estudos são necessários para aprofundar a análise dos preditores da receptividade. Sugere-se a construção de um instrumento baseado na percepção do público alvo e em conceitos precisos de aceitação e adesão, que possibilite melhor compreensão do fenômeno e estimule a adesão e o alcance de coberturas vacinais adequadas.

Factors influencing intention to obtain the HPV vaccine in South East Asian and Western Pacific regions: A systematic review and meta-analysis

Since licensing in 2006, there has been poor uptake of the HPV vaccine among the targeted population in the South East Asia Region (SEAR) and Western Pacific Region (WPR). A systematic review was conducted to identify the studies exploring the relationship between factors and intention for HPV vaccination among women in SEAR and WPR countries. Nineteen studies were identified as suitable for qualitative synthesis, and three as suitable for meta-analysis. Most women had a positive intention to have an HPV vaccine (range 57%-85%). Having a positive intention to vaccinate was significantly higher among women not aware of HPV infection (OR: 1.34, 95% CI: 1.02-1.76) and HPV vaccine (OR: 1.57, 95% CI: 1.26-1.96). Lower knowledge level and less confidence in safety and efficacy of the vaccine, negatively affected intention to vaccinate. Perceiving the vaccine to be expensive, low perception of contracting HPV infection and cervical cancer, and lack of concrete recommendations from healthcare providers also negatively affected intention to vaccinate. This review suggests the decision-making processes of women in SEAR and WPR is influenced by the cost of vaccination, perceived efficacy and safety of vaccine, provision of information on vaccination, and the awareness about HPV infection and the HPV vaccine.

Comprehensive Human Papillomavirus Genotyping in Cervical Squamous Cell Carcinomas and Its Relevance to Cervical Cancer Prevention in Malawian Women

PURPOSE

Cervical squamous cell carcinoma (SCC) continues to be a significant cause of cancer morbidity and is the third leading cause of cancer-related death in women worldwide. In sub-Saharan Africa, cervical cancer is not only the most common female cancer but also the leading cause of cancer-related deaths in women. Malawi, in particular, has the highest burden of cervical cancer. With the increasing use of human papillomavirus (HPV) vaccination, documenting the prevalent HPV types in those high-risk populations is necessary to both manage expectations of HPV vaccination and guide future vaccine development.

MATERIALS AND METHODS

In this study, we performed HPV typing on 474 cervical SCC samples and analyzed the potential impact of HPV vaccination in this population.

RESULTS

Ninety-seven percent of tumors were positive for at least one HPV type, and 54% harbored more than one HPV type. HPV 16 was the most common type (82%), followed by HPV 18 (34%), HPV 35 (24%), and HPV 31 (12%). A vaccine against HPV 16 and 18 would ideally prevent 53% of cervical SCC, and the nonavalent HPV vaccine (covering HPV 16, 18, 31, 33, 45, 52, and 58) would prevent 71% of cervical SCC in Malawi (assuming 100% vaccine efficacy). The main reason for a lack of coverage was high prevalence of HPV 35, which was also present as a single infection in a small subset of patients.

CONCLUSION

Although any HPV vaccination in this population would likely prevent a significant proportion of cervical cancer, the nonavalent vaccine would provide better coverage. Furthermore, investigation of the role of HPV 35 in this population, including possible cross-protection with other HPV types, should be pursued.

Human papillomavirus (HPV) awareness and vaccine receptivity among Senegalese adolescents

OBJECTIVE

To examine HPV vaccine awareness and receptivity among adolescents and young adults in Senegal.

METHODS

Participants from six high schools and five community centres across five regions of Senegal (n = 2286) completed a self-administered questionnaire in October and November 2014. The study assessed HPV awareness and receptivity towards receiving the HPV vaccine. Multivariable logistic regression explored statistically significant relationships between the predictor variables and both outcomes.

RESULTS

Twenty-seven percent had heard of HPV. Among those who had heard of HPV (n = 616), only 28% indicated willingness to vaccinate. Multivariable analysis showed that respondents from rural areas had 63% higher odds (95% CI: 1.24, 2.12) of having heard of HPV than those in urban areas. Respondents with fathers who had completed higher education had 41% higher odds (95% CI: 1.04, 1.92) of being aware of HPV (P < 0.05); however, every level of father's education (as compared to no education at all) was negatively associated with willingness to vaccinate. Respondents who had previously spoken to a healthcare professional about the HPV vaccine had 80% higher odds (95% CI: 1.16, 2.81) of willingness to vaccinate than those who did not speak to a provider about the vaccine.

CONCLUSIONS

Healthcare providers and parents are important stakeholders in disseminating HPV vaccine information. Given the overall low levels of awareness, there is a great opportunity for public health communication efforts to craft health messaging and information in a way to maximise receptivity, outlining benefits and providing information on the minimal risks associated with the vaccine.

Knowledge, attitudes and practices on adolescent vaccination among adolescents, parents and teachers in Africa: A systematic review

INTRODUCTION

Vaccines are the most successful and cost-effective public health interventions available to avert vaccine-preventable diseases and deaths. Despite global progress in adolescent health, many adolescents in Africa still get sick and die from vaccine-preventable diseases due to lack of vaccination. Adolescents, parents and teachers are key players in the development and implementation of adolescent vaccination policies. Optimal knowledge, attitudes and practices towards adolescent vaccination among these key players may improve vaccine uptake among adolescents. We conducted a qualitative and quantitative systematic review on knowledge, attitudes and practices of adolescent vaccination among adolescents, parents and teachers in Africa.

METHODS

We searched PubMed, Cochrane Central Register of Controlled Trials, Scopus, Web of Science, WHOLIS, Africa Wide and CINAHL for eligible quantitative and qualitative primary studies with no time limits. We also checked reference lists of included studies for eligible studies and searched grey literature. Two authors independently screened the search outputs, selected studies and extracted data; resolving discrepancies by consensus and discussion. Qualitative data were analysed using thematic analyses where applicable, while analyses from quantitative studies used different methods based on the type of outcomes.

RESULTS

We included 18 cross-sectional studies in this review. The included studies were conducted in 10 out of the 54 countries in Africa. The 18 studies focused on a wide range of adolescent vaccines. Thirteen studies evaluated vaccines against Human Papilloma Virus, while each of the remaining 5 studies, evaluated vaccines against rabies, HIV, tetanus toxoid, tuberculosis and adolescent vaccines in general. Among the key players, we found low to moderate levels of knowledge about adolescent vaccination. Positive attitudes and practices towards adolescent vaccination, especially against Human Papilloma Virus were reported. Despite the low knowledge, our results showed high levels of acceptability to adolescent vaccination among adolescents, parents and teachers.

CONCLUSIONS

It was evident in our review that all key demographics (parents, adolescents and teachers) were receptive towards adolescent vaccines. We propose relevant policy makers in Africa to consider continuous education programs such as those aimed to inform the parents, adolescents and teachers on adolescent vaccination.

Cervical cancer prevention and treatment research in Africa: a systematic review from a public health perspective

BACKGROUND

Women living in Africa experience the highest burden of cervical cancer. Research and investment to improve vaccination, screening, and treatment efforts are critically needed. We systematically reviewed and characterized recent research within a broader public health framework to organize and assess the range of cervical cancer research in Africa.

METHODS

We searched online databases and the Internet for published articles and cervical cancer reports in African countries. Inclusion criteria included publication between 2004 and 2014, cervical cancer-related content pertinent to one of the four public health categories (primary, secondary, tertiary prevention or quality of life), and conducted in or specifically relevant to countries or regions within the African continent. The study design, geographic region/country, focus of research, and key findings were documented for each eligible article and summarized to illustrate the weight and research coverage in each area. Publications with more than one focus (e.g. secondary and tertiary prevention) were categorized by the primary emphasis of the paper. Research specific to HIV-infected women or focused on feasibility issues was delineated within each of the four public health categories.

RESULTS

A total of 380 research articles/reports were included. The majority (54.6 %) of cervical cancer research in Africa focused on secondary prevention (i.e., screening). The number of publication focusing on primary prevention (23.4 %), particularly HPV vaccination, increased significantly in the past decade. Research regarding the treatment of precancerous lesions and invasive cervical cancer is emerging (17.6 %), but infrastructure and feasibility challenges in many countries have impeded efforts to provide and evaluate treatment. Studies assessing aspects of quality of life among women living with cervical cancer are severely limited (4.1 %). Across all categories, 11.3 % of publications focused on cervical cancer among HIV-infected women, while 17.1 % focused on aspects of feasibility for cervical cancer control efforts.

CONCLUSIONS

Cervical cancer research in African countries has increased steadily over the past decade, but more is needed. Tertiary prevention (i.e. treatment of disease with effective medicine) and quality of life of cervical cancer survivors are two severely under-researched areas. Similarly, there are several countries in Africa with little to no research ever conducted on cervical cancer.

Cervical cancer screening and HPV vaccine acceptability among rural and urban women in Kilimanjaro Region, Tanzania

OBJECTIVE

To determine cervical cancer screening coverage and the knowledge, attitudes and barriers toward screening tests among women in rural and urban areas of Tanzania, as well as explore how they view the acceptability of the HPV vaccine and potential barriers to vaccination.

SETTING

A cross-sectional study using interview-administered questionnaires was conducted using multistage random sampling within urban and rural areas in Kilimanjaro Region, Tanzania.

PARTICIPANTS

Women aged 18-55 were asked to participate in the survey. The overall response rate was 97.5%, with a final sample of 303 rural and 272 urban dwelling women.

PRIMARY AND SECONDARY OUTCOME MEASURES

Descriptive and simple test statistics were used to compare across rural and urban strata. Multivariate logistic regression models were used to estimate ORs and 95% CIs.

RESULTS

Most women (82%) reported they had heard of cervical cancer, while self-reported cervical cancer screening among women was very low (6%). In urban areas, factors associated with screening were: older age (OR=4.14, 95% CI 1.86 to 9.24 for ages 40-49, and OR=8.38, 95% CI 2.10 to 33.4 for >50 years), having health insurance (OR=4.15, 95% CI 1.52 to 11.4), and having knowledge about cervical cancer (OR=5.81, 95% CI 1.58 to 21.4). In contrast, among women residing in rural areas, only condom use (OR=6.44, 95% CI 1.12 to 37.1) was associated with screening. Women from both rural and urban areas had low vaccine-related knowledge; however, most indicated they would be highly accepting if it were readily available (93%).

CONCLUSIONS

The current proportion of women screened for cervical cancer is very low in Kilimanjaro Region, and our study has identified several modifiable factors that could be addressed to increase screening rates. Although best implemented concurrently, the availability of prophylactic vaccination for girls may provide an effective means of prevention if they are unable to access screening in the future.

Integrating cervical cancer prevention initiatives with HIV care in resource-constrained settings: A formative study in Durban, South Africa

Cervical cancer screening rates remain suboptimal among women in South Africa (SA), where cervical cancer prevalence is high. The rollout of HIV-related services across SA may provide a means to deliver cervical cancer screening to populations with limited access to health care systems. In this mixed methods study, psychosocial factors influencing cervical cancer prevention and perceptions of the provision of Pap smears in HIV care settings were examined. Structured interviews were conducted with women (n = 67) from a municipal housing estate in Durban, SA. Key informants (n = 12) also participated in semi-structured interviews. Findings revealed that participants had low cervical cancer knowledge, but desired more information. Relevant themes included the normalisation of HIV and beliefs that cervical cancer might be worse than HIV. A comprehensive community clinic was desired by most, even if HIV-positive patients were treated there. This study provides important insight into integrating cervical cancer screening with HIV clinics, which may increase cancer screening among South African women.

Health systems challenges in cervical cancer prevention program in Malawi

Background

Cervical cancer remains the leading cause of cancer death among women in sub-Saharan Africa. In Malawi, very few women have undergone screening and the incidence of cervical cancer is on the increase as is the case in most developing countries. We aimed at exploring and documenting health system gaps responsible for the poor performance of the cervical cancer prevention program in Malawi.

Design

The study was carried out in 14 randomly selected districts of the 29 districts of Malawi. All cervical cancer service providers in these districts were invited to participate. Two semi-structured questionnaires were used, one for the district cervical cancer coordinators and the other for the service providers. The themes of both questionnaires were based on World Health Organization (WHO) health system frameworks. A checklist was also developed to audit medical supplies and equipment in the cervical cancer screening facilities. The two questionnaires together with the medical supplies and equipment checklist were piloted in Chikwawa district before being used as data collection tools in the study. Quantitative data were analyzed using STATA and qualitative in NVIVO.

Results

Forty-one service providers from 21 health facilities and 9 district coordinators participated in the study. Our findings show numerous health system challenges mainly in areas of health workforce and essential medical products and technologies. Seven out of the 21 health facilities provided both screening and treatment. Results showed challenges in the management of the cervical cancer program at district level; inadequate service providers who are poorly supervised; lack of basic equipment and stock-outs of basic medical supplies in some health facilities; and inadequate funding of the program. In most of the health facilities, services providers were not aware of the policy which govern their work and that they did not have standards and guidelines for cervical cancer screening and treatment.

Conclusion

Numerous health system challenges are prevailing in the cervical cancer prevention program in Malawi. These challenges need to be addressed if the health system is to improve on the coverage of cervical cancer screening and treatment.

HPV vaccine acceptability in Africa: a systematic review

OBJECTIVE

The objective of this study was to provide a systematic review of peer-reviewed literature on the factors associated with HPV vaccine acceptability among adults in African countries.

METHODS

A systematic search was conducted across five electronic databases: EMBASE, PsychINFO, CINAHL, Global Health and Ovid MEDLINE, to identify studies related to HPV vaccination acceptability in African countries (August 2013). The Health Belief Model was used to guide data abstraction and synthesis.

RESULTS

Fourteen unique studies representing ten sub-Saharan African countries were identified, with more than half published within the last two years. Acceptability of the HPV vaccine for daughters was high (range 59-100%); however, vaccine-related awareness and knowledge were low. Perceived barriers including accessibility and cost concerns were important for acceptance, as were cues to action from healthcare providers and governments.

CONCLUSIONS

This review suggests that acceptability of the HPV vaccine in countries in this region will be high. Broad knowledge gaps were highlighted regarding HPV and cervical cancer and these should be addressed. Education on the vaccine's effectiveness and reducing perceived barriers to vaccination would also be useful. Public endorsement by governments and healthcare providers will likely also increase acceptance.

Cervical cancer prevention in Malawi: a qualitative study of women's perspectives

Researchers posit that cervical cancer knowledge is central to participation in prevention behaviors. However, of the many barriers to cervical cancer prevention in low- and middle-income countries, cervical cancer knowledge remains severely limited among communities at great risk for the disease. Malawi is one such country where the burden of cervical cancer is considerably high. Formative research targeting cervical cancer prevention is needed, particularly research that explores ways to deliver cervical cancer information efficiently and effectively to Malawian women. In this study, the authors aimed to garner Malawian women's understanding of cervical cancer and to shed light on preferences for health information delivery, including community health advocacy. Qualitative, in-depth interviews were conducted with 30 Malawian women and analyzed for recurring themes. In general, women had limited cervical cancer knowledge, which supported misperceptions about the disease, including factors pertaining to risk and prevention. Nonetheless, women reported that receiving cervical cancer information from trusted sources would help promote preventive behaviors. Women noted that they received most of their health information from hospital personnel, but distance was a barrier. Women also expressed interest in community health advocacy. Perspectives from Malawian women may be vital toward informing efforts to increase cervical cancer knowledge and prevention.

Acceptability of human papillomavirus vaccine: a survey among master of business administration students in KwaZulu-Natal, South Africa

Cervical cancer is a preventable public health problem. The two new human papillomavirus (HPV) vaccines are available but not accessible to everyone in South Africa, as they are very expensive. This study aimed to investigate educated peoples acceptability regarding HPV vaccination. This was a cross-sectional survey conducted among 146 master of business administration students by self-administered, anonymous questionnaire. The majority (74%) of the participants ever heard of cervical cancer, but only 26.2% heard about HPV. After reading the fact information regarding cervical cancer and HPV, the intention to vaccinate their daughters increased from 88% to 97.2% (P = 0.003). The majority (75.4%) indicated that HPV vaccination should be given before their daughters are mature enough to understand about sex, and 80.3% reported that they will discuss matters related to sex with their daughters if their daughters want to know about the vaccine. Those who did not want to vaccinate their daughters highlighted that they want more information regarding safety of the vaccine which might change their decision towards HPV vaccination. A health education information method can increase the vaccination acceptance rate in South Africa.