Targeting cervical cancer campaigns on teenage high schoolers in resource-limited economies: lessons from an intervention study of Nigerian senior secondary school girls

A systematic review of interventions to promote human papillomavirus (HPV) vaccination in Africa

OBJECTIVE

We conducted a systematic review to assess the scope and effectiveness of interventions to improve human papilloma virus (HPV) vaccination in Africa from 2006 to 2021.

STUDY DESIGN

Systematic review.

METHODS

Four databases (Medline, Embase, CINAHL and PsycINFO) were searched for articles published between 2006 and 2021. Articles were screened and included based on eligibility criteria using DistillerSR (Version 2.35). Data were extracted and reported using a narrative synthesis. A quality assessment was also conducted for each study using validated quality appraisal tools.

RESULTS

Out of 7603 articles identified by a systematic search, 18 articles met the inclusion criteria. Included studies comprised impact evaluation and cross-sectional studies published between 2012 and 2021 and conducted in eight African countries namely: Nigeria, Cameroon, South Africa, Kenya, Tanzania, Zambia, Mali, and Malawi. Study quality ranged from high to low quality. Interventions comprised fifteen educational and three multicomponent interventions. Out of thirteen impact evaluation studies (all educational interventions), twelve studies were effective in increasing HPV vaccine uptake and/or improving participants' knowledge, attitudes, and perceptions about the vaccine. Across five cross-sectional studies (two educational and three multicomponent interventions), HPV vaccine uptake rates ranged from 34% to 93.3%, with a consensus on safety and effectiveness in 67.9%-90.3% of participants post-intervention.

CONCLUSION

Educational and multicomponent interventions have been implemented to improve HPV vaccination in Africa. While educational interventions have proven effective at improving HPV vaccine uptake, a more diverse range of interventions with robust impact evaluation study designs are needed to strengthen the available evidence and improve vaccine uptake.

Communication strategies to improve human papillomavirus (HPV) immunisation uptake among adolescents in sub-Saharan Africa: a systematic review and meta-analysis

OBJECTIVES

Developing countries face the greatest cervical cancer disease burden and mortality with suboptimal immunisation uptake. This review explores the communication strategies adopted, successes, challenges and lessons learnt in sub-Saharan countries to enhance human papillomavirus (HPV) immunisation.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed, Hinari, Cochrane Library, Trip database, CINAHL, Web of Science, Scopus and seven grey resources were searched through May 2022.

ELIGIBILITY CRITERIA

We included observational studies addressing communication strategies for HPV immunisation uptake.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers used standardised methods to search, screen and code included studies. Data extraction and assessment of risk of bias were done in duplicate to enhance validity of the results. Meta-analysis was conducted using the random-effects model. Findings were summarised and synthesised qualitatively.

RESULTS

Communication intervention to facilitate decision-making achieved uptake rate of 100% (95% CI 0.99% to 1.00%), followed by intervention to enable communication, which achieved 92% (95% CI 0.92% to 0.92%). Communication intervention to inform and educate achieved 90% (95% CI 0.90% to 0.90%).Targeting both healthcare workers and community leaders with the communication intervention achieved 95% (95% CI 0.91% to 0.98%), while teachers and school boards achieved 92% (95% CI 0.84% to 1.01%). Targeting policymakers achieved 86% (95% CI 0.78% to 0.93%).Based on the method of communication intervention delivery, use of training achieved an uptake rate of 85% (95% CI 0.84% to 0.87%); similarly, drama and dance achieved 85% (95% CI 0.84% to 0.86%). However, use of information, education and communication materials achieved 82% (95% CI 0.78% to 0.87%).

CONCLUSION

HPV vaccine communication is critical in ensuring that the community understands the importance of vaccination. The most effective communication strategies included those which educate the population about the HPV vaccine, facilitate decision-making on vaccine uptake and community ownership of the vaccination process immunisation.

PROSPERO REGISTRATION NUMBER

CRD42021243683.

Features of human papillomavirus vaccination education strategies in low- and middle-income countries: a scoping review

OBJECTIVE

We aimed to describe studies on human papillomavirus (HPV) vaccination education strategies from low- and middle-income countries in the published literature that could be applicable in Sub-Sahara Africa.

STUDY DESIGN

This scoping review was guided by Arksey and O'Malley's methodological framework advanced by Levac et al.

METHODS

We searched four electronic health sciences databases for relevant reports published between January 2006 and January 2021. Two reviewers screened for inclusion and extracted data for analysis and synthesis. Descriptive statistics and narrative descriptions were used to summarize the findings.

RESULTS

The database search retrieved 1757 reports, of which 48 were from low- and middle-income countries and met the inclusion criteria. Of these, there were 39 interventional studies (81.3%). Less than one-fifth of the studies (n = 9) reported a theoretical basis for their strategies. Most strategies sought to improve knowledge and awareness about HPV (75%, n = 36), whereas outcomes for the remaining studies were related to increasing HPV vaccine acceptability. HPV education strategies (1) primarily targeted females, (2) were mostly provided by health professionals, and (3) used various modalities of learning, including in-person sessions, text-based materials, media, theater, and online delivery.

CONCLUSIONS

HPV educational strategies are underresearched in most LMICs, suggesting the need for more primary observational, interventional, and experimental research, as well as program evaluations, focused on HPV educational strategies and theoretically informed. Once additional studies are added to the body of evidence, it will be valuable to review and synthesize diverse sources of evidence to determine what educational strategies are most useful and have the greatest impact on HPV vaccination in these settings, particularly Sub-Saharan Africa.

The effectiveness of health education interventions on cervical cancer prevention in Africa: A systematic review

Low levels of knowledge and awareness on cervical cancer play a role in limiting cervical cancer prevention uptake. This systematic review aimed to identify effective educational interventions to increase cervical cancer awareness, knowledge, and subsequently screening or vaccination uptake in African women. A literature search was conducted in Medline and EMBASE databases. We examined original, peer-reviewed English literature published between 2005 and 2020. Nineteen studies examining health education interventions' impact on awareness, knowledge, and screening or vaccination uptake in African women were included. Ten studies were controlled trials, nine performed pre- and post-measurements in one group. Most studies were published between 2015 and 2020 (86%), many were from Nigeria (47%). Studies were mostly set up in communities and schools. The most frequently used intervention was lectures, alone or combined with videos and practical demonstrations. Sixteen studies evaluated knowledge or awareness, and all showed a statistically significant improvement following the intervention. Of the ten studies that evaluated screening uptake, either as the single outcome or combined with knowledge or awareness, six found a significant rise in screening uptake after intervention. Educational interventions increased knowledge and awareness in African women, some boosted uptake of cervical cancer screening, especially when using peer health educators and culturally tailored methods. Innovative approaches such as self-collected HPV testing and mHealth also demonstrated a potential to increase uptake of screening. More research is needed to identify and analyse barriers to screening uptake, which can still be present even after a successful educational intervention.

Effectiveness of interventions for improving timely diagnosis of breast and cervical cancers in low-income and middle-income countries: a systematic review

OBJECTIVES

To systematically synthesise available evidence on the nature and effectiveness of interventions for improving timely diagnosis of breast and cervical cancers in low and middle-income countries (LMICs).

DESIGN

A systematic review of published evidence. The review was conducted and reported in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses.

DATA SOURCES

A comprehensive search of published literature was conducted. In addition, relevant grey literature sources and bibliographical references of included studies were searched for potentially eligible evidence.

STUDY SELECTION

Studies published between January 2010 and November 2020 were eligible for inclusion. To be eligible, studies had to report on interventions/strategies targeted at women, the general public or healthcare workers, aimed at improving the timely diagnosis of breast and/or cervical cancers in LMIC settings.

DATA EXTRACTION AND SYNTHESIS

Literature search, screening, study selection, data extraction and quality appraisal were conducted by two independent reviewers. Evidence was synthesised and reported using a global taxonomy framework for early cancer diagnosis.

RESULTS

From the total of 10 593 records identified, 21 studies conducted across 20 LMICs were included in this review. Most of the included studies (16/21) focused primarily on interventions addressing breast cancers; two focused on cervical cancer while the rest examined multiple cancer types. Reported interventions targeted healthcare workers (12); women and adolescent girls (7) and both women and healthcare workers (3). Eight studies reported on interventions addressing access delays; seven focused on interventions addressing diagnostic delays; two reported on interventions targeted at addressing both access and diagnostic delays, and four studies assessed interventions addressing access, diagnostic and treatment delays. While most interventions were demonstrated to be feasible and effective, many of the reported outcome measures are of limited clinical relevance to diagnostic timeliness.

CONCLUSIONS

Though limited, evidence suggests that interventions aimed at addressing barriers to timely diagnosis of breast and cervical cancer are feasible in resource-limited contexts. Future interventions need to address clinically relevant measures to better assess efficacy of interventions.

PROSPERO REGISTRATION NUMBER

CRD42020177232.

HPV vaccine acceptance in West Africa: A systematic literature review

Human papillomavirus (HPV) infections are mostly sexually transmitted and cause the greatest share of infection-associated cancers. Each year more than half a million women are diagnosed with cervical cancer and the mortality rate in West Africa is over ten times higher than that of Northern Europe. HPV vaccines are highly effective at preventing various strains of the infection. However, vaccine hesitancy and access issues have led to low HPV vaccine acceptance in certain countries. A search strategy was developed in PubMed and included an extensive list of keywords and related MeSH/subject headings to capture the many dimensions and expressions of vaccine access, confidence, trust and hesitancy related to HPV vaccination in West Africa. Thirty-five articles were included by full text. Most studies were conducted in Nigeria. Three were conducted in Mali, and one each in Côte d'Ivoire, Ghana and Senegal. The main concerns relating to the vaccine were inadequate information, cost and safety concerns. Several studies also mentioned fertility and promiscuity concerns. Despite over half of West African countries introducing an HPV vaccine pilot project, there is a scarcity of literature on HPV vaccine acceptance in the region. It is important to understand how cultural and gender dynamics in different settings can influence peoples' vaccination decisions. This can be done through in-depth local ethnographies, taking the views of all community members and influencers into account, and complemented by in-depth individual interviews and focus groups.

Re-thinking breast and cervical cancer preventive campaigns in developing countries: the case for interventions at high schools

BACKGROUND

The negative impact of cervical and breast cancers in low and lower-middle income countries are worsening, and, along with other non-communicable diseases, occur disproportionately in these resource-limited economies. Most preventive approaches to these cancers require government funding, but few countries with the most at-risk population can afford government-sponsored universal vaccination, screening, diagnostic and treatment programmes, which, along with socioeconomic issues, contribute to the poor outcomes in these mostly developing countries. An urgent need exists, therefore, to find an effective, affordable, cost-effective, culturally-acceptable and sustainable way of reducing these cancers. This paper advocates a re-thinking in the current preventive campaigns.

MAIN BODY

Using evidence provided by recently-published papers, a case is made for enlightenment campaigns to primarily target teenagers (boys and girls) in high schools of developing countries. Inclusions into the schools' academic curricula are the recommended approach, given that both cancers take hold on populations within that age bracket. This approach, if adopted, may be the only accessible, affordable and realistic approach that gives millions of women in low and lower-middle income countries the chance at survival. Empowering them early instils the self-awareness and confidence necessary for young adults to take charge of their own health. The acquired knowledge, in turn, helps them adopt positive attitudes and preventive behaviours that will, ultimately, prolong their lives.

CONCLUSION

The recommended approach offers governments and concerned stakeholders an evidence-based option that allows them to deliver cost-effective and sustainable life-saving interventions, while hoping to get around the bottlenecks that limit the large scale implementation of other effective but capital-intensive strategies.