"She must have been sleeping around"…: Contextual interpretations of cervical cancer and views regarding HPV vaccination for adolescents in selected communities in Ibadan, Nigeria

Pursuance of a Yoruba name for cervical cancer in Southwest Nigeria: a case study

OBJECTIVES

Participants' comprehension of research process affects the quality of research output, which is the reason why translation of research instruments into local languages is standard practice. Literature has consistently reported that in Africa, knowledge about cervical cancer is low but paradoxically, expressed, and actual uptake of human papillomavirus vaccine for its prevention is high. This study explored the Yoruba names of cervical cancer among Yoruba people in Ibadan, Nigeria to guide the translation of cervical cancer research instruments to Yoruba language.

DESIGN

Exploratory case study design was used and data were obtained with 10 in-depth interviews and four focused group discussions. Data were analysed using content analysis.

SETTINGS

The study took place in Ibadan North local government area, Southwest Nigeria.

PARTICIPANTS

These were 4 traditional healers, 3 Yoruba linguists, 3 public health educators and 38 parents of adolescents.

MEASURES

These were Yoruba names for cervical cancer and their meanings.

RESULTS

Participants were aware of cervical cancer but only the traditional healers and public health educators had names for it. These names were highly varied. The public health educators gave names that were linked with different parts of the female reproductive system and external genital which were actually different medical conditions. Each traditional healer also had different names for cervical cancer, which either described the female body parts, or symptoms of female genital infections. These various names can lead to unnecessary misconceptions and misinformation about cervical cancer, its prevention, management, and research.

CONCLUSIONS

There was no consensus Yoruba name for cervical cancer among the study participants. Efforts to educate the Yoruba speaking populace about cervical cancer, its prevention, management and participation in its research can be frustrated if a generally accepted Yoruba name is not provided for this cancer. Stakeholders' collaboration is required to get an appropriate Yoruba name for cervical cancer.

Determinants of Human Papillomavirus Vaccine Acceptance among Caregivers in Nigeria: A Fogg Behavior Model-Based Approach

Human papillomavirus (HPV) vaccine uptake among adolescent girls is critical to reducing the burden of HPV-related cancers in Nigeria. This study assesses the factors influencing caregivers' acceptance of HPV vaccination for their charges, using the Fogg Behavior Model (FBM) as a theoretical framework. We analyzed cross-sectional data from 1429 caregivers of girls aged 9-17 in six Nigerian states, using a survey instrument based on the FBM. Participants were recruited via Facebook and Instagram advertisements and interviewed through Facebook Messenger in August and September 2023. The study received ethical clearance from Nigeria's National Health Research Ethics Committee. We applied bivariate and multivariate analyses to assess the relationships between the caregiver's perception of how likely their adolescent girl was to get vaccinated in the next 12 months and motivation, ability, social factors (such as discussions with family and friends), injunctive norms, previous COVID-19 vaccination, and respondents' sociodemographic characteristics. Adjusted odds ratios derived from logistic regression analyses revealed that caregivers' motivation and ability, as well as social factors, were significantly associated with their perception that the adolescent girl in their care would get vaccinated within the next 12 months. Our findings suggest that behavioral interventions tailored to enhance motivation, ability, and social support among caregivers could significantly increase HPV vaccine uptake among adolescent girls in Nigeria.

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.

Stated preferences for human papillomavirus vaccination for adolescents in selected communities in Ibadan, Southwest Nigeria: A discrete choice experiment

Administration of the human papillomavirus (HPV) vaccine in early adolescence is effective in preventing cervical cancer, a common cancer in sub-Saharan Africa. Nigeria is in the pre-introduction era of the HPV vaccine. Understanding the preferences of the population for the vaccine can help design the HPV immunization program to ensure high uptake of the vaccine. This study explored the preferences for the HPV vaccine among stakeholders in selected communities in Ibadan, Nigeria. A discrete choice experiment survey based on six attributes of the HPV vaccine (which were the number of doses, the efficacy of the vaccine, cost of the vaccine, location of the service point, other benefits of the vaccine apart from prevention of cervical cancer and the odds of a side effect from the vaccine) was carried out in five communities. Data were analyzed using conditional and mixed logit models. Seven hundred community members were recruited, 144 (20.7%) were adolescents and 248 (35.4%) were males. In line with expectations, respondents preferred vaccines with higher efficacy, less severe side effects and lower costs. Preference heterogeneity was identified for adolescents that were less price-sensitive and other community members who were less likely to prefer using schools as the service point. The high socioeconomic class preferred a vaccine that also prevents genital warts. There were variabilities in the preferences for the attributes of the HPV vaccine in the study communities. These variabilities need to be considered in the introduction of the HPV vaccine to ensure high uptake of the vaccine.

Challenges and lessons from a school-based human papillomavirus (HPV) vaccination program for adolescent girls in a rural Nigerian community

Background

Over 80% of new cervical cancer cases occur in women living in low- and middle-income countries. It is the second highest cause of female cancer deaths in Nigeria. School based vaccination programs are an effective strategy for delivering the HPV vaccine to adolescent girls. This study aims to understand the challenges to implementing school-based HPV vaccination programs, particularly in a remote rural setting where vaccine hesitancy is high.

Methods

A 22- item interviewer administered questionnaire was used to evaluate HPV knowledge and willingness to get the HPV vaccinate among 100 female secondary school students as part of an HPV vaccination pilot in a rural community in Kebbi State, Nigeria. Additionally, semi-structured interviews were used to assess community knowledge and attitudes on cervical cancer and HPV vaccination. Data collected were analyzed thematically to understand challenges and generate lessons for vaccine delivery in the study setting.

Results

Knowledge of HPV and cervical cancer among junior secondary school aged girls was fair with a mean score of 66.05%. For senior secondary school aged girls, the knowledge score ranged from 70 to 100% with a mean of 96.25% indicating good knowledge of HPV and cervical cancer. All participants (n = 100) received the first vaccine dose but due to COVID-19, 33 participants were not able to complete the vaccine dosage within the recommended 6-month schedule. Of the parents who provided consent, none could afford the vaccine out of pocket. Challenges to vaccine delivery included operational costs exacerbated by lack of adequate health workforce and infrastructure in the study setting.

Conclusion

An exploration of sociocultural perspectives and contextual realities is crucial to understanding the complexities of HPV vaccine introduction from the perspective of the target audience, and the local community. Strategies for introducing the HPV vaccine should address community concerns through effective communication, appropriate delivery, and targeted advocacy to make the vaccination program locally relevant. While school-based HPV immunization programs have been shown to be successful, adequate design, planning and monitoring is important. Additionally, considerations must be made to account for the high operational cost of vaccine delivery in rural, hard to reach areas where human resources and infrastructure are limited.

Parental intention to vaccinate adolescents with HPV vaccine in selected communities in Ibadan, Southwest Nigeria: an application of Integrated Behavioral Model

Parents have important roles to play for adolescents to get the human papillomavirus (HPV) vaccine, an effective measure in the prevention of cervical and other HPV-related cancers. It is important to understand the intention of parents to have their adolescents vaccinated for optimal uptake of the vaccine in Nigeria. This study investigated the intention of parents in five selected communities to get their adolescents vaccinated with HPV vaccine in Ibadan, Nigeria using the Integrated Behavioral Model (IBM). Cross sectional study design was employed and 678 parents were interviewed. Pearson correlation, chi-square test and multiple regression were used for data analysis at α = 0.05. Mean age of the parents was 42.5 ± 10.0 years and 230(33.9%) were males. Almost all of the parents (96.8%) had the intention to vaccinate their adolescents with HPV vaccine. This intention was significantly correlated with experiential attitude (r = 0.74, p = <.01), instrumental attitude (r = 0.33, p = <.01), injunctive norm (r = 0.39, p = <.01), descriptive norm (r = 0.32, p = <.01), perceived control (r = 0.32, p = <.01) and self-efficacy (r = 0.46, p ≤ .01). A higher proportion of parents older than 65 years significantly had no intention to vaccinate their adolescents with HPV vaccine. Intention to vaccinate adolescents with HPV vaccine was predicted by experiential attitude (OR = 0.88, 95% CI: 0.80-0.95), personal agency (OR = 0.22, 95% CI: 0.15-0.29) and injunctive norm (OR = 0.08, 95% CI: 0.02-0.13). Parental intention to vaccinate adolescents with HPV vaccine was high among the parents in this study. The reluctance of older parents about HPV vaccine for adolescents requires further investigation.

Cervical Cancer and Human Papillomavirus Vaccine Knowledge, Utilisation, Prevention Educational Interventions and Policy Response in Nigeria: A Scoping Review

PURPOSE

This review evaluated the knowledge, utilisation, prevention education, and policy response across the six geopolitical regions of Nigeria to inform national efforts for the prevention and control of cervical cancer.

METHODS

A keyword-based systematic search was conducted in PubMed/MEDLINE (NCBI), Google Scholar, and AJOL electronic databases, including a manual scan of papers, journals and websites to identify relevant peer-reviewed studies. Articles were screened and assessed for eligibility.

RESULTS

Many (158) articles were downloaded and after duplicates were removed, 110 articles were included in the final analysis. These were made up of qualitative, quantitative (cross-sectional), intervention and policy studies. Studies have generally reported poor knowledge and awareness of cervical cancer screening but those carried out in urban areas demonstrated a slightly higher level of awareness of Human Papilloma Virus (HPV) vaccine, HPV vaccination uptake and utilization of cervical cancer preventive services than the rural studies. The studies did not show strong government support or policies in relation to cervical cancer control.

CONCLUSION

Knowledge and uptake of cervical cancer preventive services across diverse groups in Nigeria remain poor. These could be linked to socio-cultural factors, the lack of an organised cervical cancer screening programme and low financial resource pool for cervical cancer prevention. Therefore, it is necessary to increase government, donor prioritisation and political support in order to ensure increased investment and commitment to cervical cancer elimination in Nigeria.

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.

Effect of human papilloma virus vaccination on sexual behaviours among adolescent women in Rwanda: a regression discontinuity study

Increasing human papilloma virus (HPV) vaccination coverage is one of the key approaches to preventing cervical cancer globally. However, some argue that HPV vaccine recipients may engage in risky compensatory sexual behaviours because of perceived protection afforded by the vaccine. Therefore, we investigated the impact of a wide-scale HPV vaccination programme on sexual behaviours among adolescent women in Rwanda-the first African country to implement a national HPV vaccination. We identified a cohort of women who were eligible for the HPV vaccination and those who were not eligible from the most recent Rwanda Demographic and Health Survey. We used a quasi-experimental regression discontinuity design, exploiting the quasi-random change in HPV vaccination eligibility in 2011, to compare sexual behaviours among vaccinated and unvaccinated adolescent women. We studied the impact of the vaccination on reported sexual intercourse, average number of sexual partners and teenage pregnancy across the vaccination eligibility threshold. Our analysis included 3052 adolescent women (mean age: 18.6 years), of whom 58% were eligible for HPV vaccination. Nearly one in five adolescents reported having had sexual intercourse (18.5%). The average reported lifetime number of sexual partners was 1.41. The proportion of teenage pregnancy was 5.3%. We found no evidence that HPV vaccination was associated with any significant changes across the eligibility threshold in reported sexual behaviours we studied: no significant increase in the proportion of having sexual intercourse [odds ratio (OR): 0.80, 95% confidence interval (CI): 0.57-1.12; P = 0.19], in lifetime number of sexual partners (rate ratio 0.99, 95% CI: 0.83-1.17, P = 0.91) and in the proportion of teen pregnancies (OR 1.05, 95% CI: 0.50 to 2.20, P = 0.89) at the eligibility threshold. The Rwandan national HPV vaccination programme did not increase sexual behaviours among adolescent women, assuaging concerns of engaging in risky compensatory sexual behaviours some have feared.

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.

Modeling for Predictors of Knowledge Score on Etiology and Prevention Strategies for Cervical Cancer Among Women of Reproductive Age in Ibadan

PURPOSE

Poor knowledge regarding cervical cancer in at-risk populations directly affects health-seeking behavior and is associated with high mortality among women with cervical cancer. This study aims to evaluate the knowledge of women regarding the causes, risk factors, and prevention strategies of cervical cancer.

METHODS

A multistage cross-sectional study of 1,002 women of reproductive age (18-49 years) in Ibadan was conducted. Knowledge of cervical cancer risk causes and prevention strategies was assessed using 13 and 9 question items, respectively. The knowledge score was graded as 0 (no knowledge), 1-4 (poor knowledge), or ≥ 5 (good knowledge). The proportional or partial proportional odds model was used to fit 3 models using the forward stepwise selection. All analysis was performed using Stata 15.0 (Stata Corp, College Station, TX).

RESULTS

The median age of participants was 29 years (interquartile range [IQR], 23-35 years). The median knowledge scores of participants on causes and prevention strategies of cervical cancer were 3 (IQR, 0-4) and 3 (IQR, 0-5), respectively. The assessment of knowledge on causes and prevention strategies for cervical cancer revealed that having multiple sexual partners and no previous opportunity for counseling on cervical cancer screening were factors associated with lower odds of knowledge.

CONCLUSION

The knowledge of women about the risk factors, causes, and prevention strategies of cervical cancer was poor. It is worrisome that poor knowledge was common among women with potential demographic risk factors for cervical cancer. We recommend innovative community mobilization to improve women’s knowledge of the risk factors associated with cervical cancer and prevention strategies.

Immunization Campaigns and Strategies against Human Papillomavirus in Italy: The Results of a Survey to Regional and Local Health Units Representatives

Objective. The study aimed to assess the impact of HPV immunization campaigns organizational aspects, the characteristics of immunization program (vaccination targets and type of offer), and communicative strategies adopted by four Italian administrative regions on vaccination coverage observed. Methods. From November 2017 to March 2018, regional and Local Health Units (LHUs) representatives were invited to complete an online survey including 54 questions evaluating vaccination invite systems, access systems to vaccination centres, reminder and recall systems, and adverse events surveillance. An overall descriptive analysis was conducted. Since observed vaccine coverage (VC) obtained in females (2002-2004 birth cohorts) was lower than objectives fixed by the Italian Ministry of Health, variables were assessed using the national VC mean obtained in the 2003 girls birth cohort as outcome. Results. Twenty-six LHUs belonging to 4 Northern and Southern Italian regions participated in the study. Organizational aspects significantly related to VC lower than the national mean were access to vaccine centres without appointment and parents' reservation as appointment planning system. Recall systems for both the first and the second dose, including the appointment in the invitation letter, the availability of regional immunization registry, and education of healthcare workers on universal HPV immunization strategies, instead, were related to higher VC. As regards preadolescent immunization strategies, both VC obtained in girls and boys were far from the Ministerial goals. Only 20% of LHUs introduced multicohort female strategies while all LHUs adopted copayment targeting both men and women. Immunizations strategies targeting subjects at risk were implemented only in half of participating LHUs. Conclusions. VC observed in participating LHUs are largely lower than the national objectives in all anti-HPV vaccine targets. Both organizational and educational strategies have to be implemented to improve the VC goals.