Planning, Implementation, and Sustaining High Coverage of Human Papillomavirus (HPV) Vaccination Programs: What Works in the Context of Low-resource Countries?

"Since HPV vaccination programs are relatively new in LLMICs, national decision-makers have faced several introductory challenges in addition to the global shortage of HPV vaccine including ...community level communication, targeting hard to reach populations..., tailoring delivery and communication approaches to sub-national level, and determining how to maximize coverage..."

Cervical cancer due to human papillomavirus (HPV) infection is a leading cause of mortality among women in low-resource settings. Many Sub-Saharan African countries have introduced HPV vaccination programs at the national level in the last few years. However, countries are struggling to maintain sustainable coverage. Drawing on published data and key informant interviews, this study aimed to summarise context-specific lessons learned from recent HPV vaccination programme introductions, develop a deeper understanding of facilitators and barriers to HPV vaccination programmes, and identify key areas for achieving sustainable coverage in low and lower-middle-income countries (LLMICs).

In August 2021, the researchers performed a systematic literature search using a combination of different keywords, including individual names of LLMICs in Asia and Africa that had introduced or planned to introduce HPV vaccination programmes between 2018 and 2021. Ultimately, they analysed 43 peer-reviewed articles and 13 grey literature documents. In addition, from February 2022 to April 2022, they also interviewed (via Zoom) 18 national HPV experts from 8 national programmes in Asia and Africa to gain insight into HPV vaccine introduction experiences and associated challenges in their respective countries.

The paper discusses results according to the following themes: preparation and planning, implementation, social mobilisation and communication, impact of COVID-19 on HPV vaccination programmes, and sustainability. Selected highlights include:

• Local data availability was a challenge across countries, with the lack or absence of registries, data collection, and reporting mechanisms.
• Multi-sectoral coordination and early involvement of key stakeholders were cited as an integral part of HPV programmes and facilitators for sustainable coverage. However, interview findings provided an in-depth understanding of the challenges to partner coordination; for example, involvement of international stakeholders via different national stakeholders created lack of ownership.
• Health workforce mobilisation was deemed fundamental to ensure that the health workforce is aware of the disease etiology and eligibility requirements and that they can dispel misinformation. One of the emerging findings from the study was the critical need to focus on healthcare provider (HCP) training content and refresher training due to staff turnover. All key informants voiced the need for periodic training, including on responding to rumours about HPV vaccines. Optimal training and involvement of teachers was identified as a facilitator for sustainable coverage.
• Schools were reported to be an ideal sustainable platform for vaccination. However, this scenario required teachers to be trained, which was often not considered in the programmes. District-level staff were often poorly informed and lacked the technical and logistic capacity to support vaccination rounds and data collection.
• ICOVID-19 overstretched the system, leaving less room for HPV-related activities in low-resource countries. Key informants indicated that HPV vaccination programmes have very low priority across programmes, compounded by parents being hesitant to bring their daughters to healthcare facilities (e.g., in Côte d'Ivoire) especially during the COVID-19 pandemic, since it was difficult to conduct outreach activities. The drop in coverage across all countries calls for consolidated back-up plan for delivery yet requires in-depth case studies to learn from resilient examples such as Ethiopia and Rwanda.
• To improve the sustainability of HPV vaccination programmes, there is a need for timely microplanning, improved partnerships among stakeholders, health workforce mobilisation and capacity building, efficient preparedness assessment, research on sustainable delivery approaches, strengthening of health information systems, discovery of innovative ways to achieve equity, and adoption of a bottom-up approach that centres the voices of local stakeholders.

With regard to social mobilisation and communication in particular:

• A variety of key stakeholders and communications channels are needed, given the intended age group and the need for prior sensitisation within communities and professional organisations. It also requires a well-thought-out plan and funding for sustainability beyond the initial introduction.
• Some countries (Tanzania, Zimbabwe, Senegal, Zambia, Kenya) had communication plans in place that included guidelines for advocacy and sensitisation meetings, mass media involvement, launching ceremonies, identification of priority groups, and activities and materials meant for each priority group, as well as a crisis management plan.
• For example, printed products containing key messages were developed and distributed to schools, communities, and healthcare facilities through mass and social media. Senegal and Zimbabwe conducted radio broadcasts for communication and social mobilisation activities, which proved to be very useful in remote areas with limited or no access to television, and communication was tailored to local languages. Kenya supplemented these activities with talk shows and mass social media outreach. In Côte d'Ivoire and Senegal, WhatsApp groups have been used to communicate effectively between programme managers and HCPs to tackle emerging HPV vaccine misinformation.
• In terms of message content, the Ugandan experience demonstrated that simple messages to girls, especially regarding vaccine safety and efficacy, are useful for vaccine uptake.
• Key informants reported limited supply of social mobilisation and communication materials (e.g., flyers and posters) as a challenge, and in-depth programme evaluation reported that communication material was sent to district level without any instructions. In response, key informants emphasised the need for periodic sensitisation and circulation of communication material.
• Not all the planned communication activities translated into high uptake of HPV vaccine. Some critical facilitators included: early mobilisation of stakeholders at all levels, involvement of political and religious leaders and journalists in national and regional stakeholder meetings to timely address the rumours about HPV vaccine affecting fertility, and sufficient funding to conduct periodic sensitisation activities.

Figure 2 in the paper discusses domain-specific barriers that can be addressed with a set of actions to help achieve a sustainable HPV vaccination programme. One suggested mechanism of action related to multi-sectoral coordination is to have a prioritisation framework outlining vaccine prioritisation processes and promoting use of terms of reference to outline the composition, roles, and responsibilities of different stakeholders - e.g., one that defines how the health workforce collaborates with teachers and community leaders during vaccination sessions and that promotes a strong national ownership framework.

In conclusion, this study "documented the gaps in data collection and reporting mechanisms, the importance of multi-sectoral coordination, and the need to proactively engage stakeholders (such as the Ministry of Education) with a defined framework. Furthermore, it covered HPV delivery and training approaches, highlighting the need for context-specific implementation research through a series of recommendation[s]....Key informants reported the need for coordinated investment for periodic training of the health workforce, contextualized messages for communication and innovative approaches for hard-to-reach target populations."