Global Perspectives of Determinants Influencing HPV Vaccine Introduction and Scale-up in Low- and Middle-Income Countries

"As more countries introduce HPV vaccines into their national immunization programs and develop plans for scaling up vaccination efforts, strategic approaches in communications, advocacy, and social mobilization must be developed to increase vaccine uptake."



Although low- and middle-income countries (LMICs) account for the majority of cervical cancer cases globally, scale-up of HPV vaccine programmes and progress toward coverage targets in LMICs has been hampered by factors including health system constraints, patient barriers, policy barriers, and challenges related to the COVID-19 pandemic. This qualitative study interviewed 13 global stakeholders categorised as either academic partners or global immunisation partners to ascertain their perspectives regarding determinants affecting HPV vaccine introduction and scale-up 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.



Interviews were conducted between January and June 2022. Participating academic partners represented five countries, and participating global immunisation partners represented five World Health Organization (WHO) regions. The themes that emerged during interviews were categorised into upstream and downstream determinants of HPV vaccine introduction and scale-up:

1. Upstream determinants were defined as macro-level factors that impacted programme introduction and scale-up and included financial considerations, vaccine prioritisation, global supply, capacity and delivery, and vaccine accessibility, equity, and ethics. Here are three examples:
   • Health systems in many LMICs are ill-equipped to successfully address adolescent health issues. This is partly attributable to healthcare providers not receiving sufficient training in providing care to adolescents, limited experience discussing sensitive issues regarding sexual and reproductive health, and provider stigma. Stakeholders emphasised the efficacy of school-based delivery platforms and integrated adolescent health services.
   • The results confirm that strong political commitment and governance are major factors for successful HPV vaccine introduction and scale-up. Several examples were given of various Ministers championing HPV vaccines due to their gender or professional background. To enhance political buy-in, stakeholders need access to relevant data points (e.g., local disease burden), particularly in the context of competing health priorities.
   • Vaccine equity was mentioned as critical for scale-up, especially the importance of vaccinating boys. Stakeholders reported that in many instances, communities questioned why girls are selected for vaccination instead of boys, which may lead to skepticism, hesitancy, and decreased uptake.
2. Downstream determinants were defined as community-level factors that influenced successful vaccine introduction and scale-up, including vaccine acceptability and hesitancy and communications, advocacy, and social mobilisation. Here are three examples:
   • As HPV and cervical cancer are seen as a women's reproductive health issue that is considered taboo in many settings, the topic is linked to significant stigma, which in turn perpetuates misinformation. Stakeholders questioned how demand can be generated for a vaccine targeting a disease that is stigmatised and relatively invisible.
   • Rumours have added to vaccine hesitancy. One participant, an academic researcher, discussed this issue in the context of polio: "You know, polio is a viral infection, and a virus of global public health importance, and the whole world is attempting to eradicate polio....People introduce some conspiracy....there were a lot of insinuations that this is a vaccine that was primarily introduced just to control people's fertility, and in the process also control their reproduction and population. So, what do you expect when you now introduce another vaccine?..." Several stakeholders stressed that vaccine hesitancy is widespread not only among adolescents and parents, but also among policymakers, educators, and healthcare providers.
   • All participants emphasised the need to increase funding for communications, both during and after vaccine introduction. Global immunisation partners indicated that many countries employed communication strategies that worked for other vaccines but that were ineffective for HPV vaccines. There is a need to generate evidence and lessons learned from past HPV vaccine communication strategies to inform the development of future communication interventions.

Reflecting on the findings, the researchers argue that "Efforts to enhance advocacy and communications will be essential to increase the demand for HPV vaccines and raise cervical cancer as a pressing public health issue. Advocacy and communications efforts are needed to not only target adolescents and parents, but to also target healthcare providers, educators, and policymakers. Communications must be broad-based and accessible to influence knowledge, beliefs, attitudes, and practices toward HPV vaccines, as this will be critical in expanding vaccine uptake."



In conclusion, the researchers call for "continuous engagement between key stakeholders to facilitate the development of evidence-driven, adolescent-centered strategies to increase HPV vaccine scale-up by enhancing access, equity, communications, advocacy, and social mobilization while reducing vaccine hesitancy. Efforts must be placed in ensuring that stakeholders recognize cervical cancer elimination as a worthwhile investment that should be prioritized."