Human Papillomavirus Immunisation of Adolescent Girls: Improving Coverage through Multisectoral Collaboration in Malaysia

"Malaysia's health sector has long benefited from a culture and environment that support intra-agency, interagency, and multisectoral collaboration..."

This article presents a case study of the human papillomavirus (HPV) programme and explores the role of multisectoral collaboration in achieving near-universal immunisation of an estimated annual cohort of 250,000 13-year-old girls. The aim is to identify key factors in the successful collaboration, particularly during policy formulation, planning, and initial implementation, and to report lessons learnt.

The objective of the HPV immunisation programme was the eventual reduction in the burden of cancer, and this was to be achieved by vaccinating 13-year-old girls through the existing school health programme. Figure 1 outlines the programme timeline - from the policy formation phase (2006-09), through the planning and implementation phase (2009-11, which included the development of the communication strategy for the first 2 years via messages sent through different traditional and social media), and into the sustained implementation phase (2012-16 and to present). From 2012, free HPV immunisation was fully integrated into the school health programme and is a key component of the national childhood immunisation programme.

Parental consent for daughters to receive the HPV vaccination has been more than 95% from year one of the programme. Of those for whom parental consent was given, completion of 3 doses has been more than 98%. Population coverage has been more than 80% throughout, and adverse events following immunisation (AEFIs) have been low, ranging from 0.06% to 0.45%.

The researchers identified 2 themes that underpinned the success of the collaboration:

1. Collaborative work in planning and monitoring: The introduction of the HPV immunisation programme energised the long-established interagency collaborative network of joint school health committees. Vertical collaborations between national, state, district, and local levels of the ministries of health and education supported information flow and accountability. At the same time, horizontal linkages between the two sectors at each level supported information exchange and strengthened trust. Monitoring of HPV immunisation was integrated into the monitoring system of the ongoing school health programme.
2. Collaborative work in communication: Focus group discussions carried out among students by the Ministry of Health (MoH) communications team indicated widespread confusion between HIV and HPV, as well as concerns that the vaccine would promote sexual promiscuity, have serious unanticipated side effects, and contravene Islamic law. In response, the MoH designed a 2-pronged, partnership-oriented communication strategy that enhanced collaboration with both the education sector and the mass media. Key aspects:
   • Training and support packages were implemented for frontline staff, such as teachers and school health teams, who were known to be key influencers of the perspectives and behaviour of students and parents.
   • The MoH worked with the media to mobilise public opinion in favour of immunisation, empower parents to consent to immunisation for their daughters, and provide appropriate and timely information to address individual concerns. The collaboration was based on a contractual agreement and strong interpersonal relationships.
   • Using its positive image as an agency devoted to public welfare, the MoH obtained primetime radio and television slots at reduced rates. Mass media in 4 languages (Bahasa Malaysia, English, Chinese, and Tamil) were used to inform and motivate the general public, especially parents. The key message was "HPV immunisation given when your daughters are young will protect them when they eventually get married".
   • The MoH used Facebook, Twitter, and a dedicated telephone hotline to provide a direct channel for parents and the general public to raise concerns and receive immediate responses from informed and credible professionals.
   • The MoH provided evidence to the national Islamic religious authority (JAKIM) that the vaccine met Islamic requirements. As a result, this authority issued a fatwa that the vaccine was permitted for use in the interest of protecting women against cervical cancer. The fatwa was used widely in briefings for teachers, parents, and schoolchildren and in road shows (information briefings and meetings for members of the public).
   • Other activities included monitoring rumours about HPV vaccination and responding promptly to them, and monitoring AEFIs (see table 5).

As reported here, the value systems and priorities that have governed health system development in the country include a focus on prevention, community participation, safety and quality, creative innovations, accountability, and sustainability. The HPV immunisation programme illustrates the value of "patient before patent" and an engagement rather than an authority approach to partnership. Factors supporting effective multisectoral collaboration in this context included:

• Between the health and education sectors: Mutual trust and respect were built through timely exchange of specific information, such as training packages, the key message, informed consent from parents, and monitoring AEFIs.
• Between the health sector and news media: Transparent, credible, and timely communication was maintained on issues such as Islamic halal requirements and AEFIs.
• Between the health sector and parents and schoolchildren: Engagement rather than advocacy was used; parents were treated as partners in the programme and had convenient and simple access to authorities to discuss and resolve concerns.

More specifically, as outlined in the case study, a key success factor in the collaborations was the reshaping of relationships, away from supervisor-subordinate, manager-helper, or manager-client to true partnership. An important condition for this was the 3 layers of strong leadership within the MoH. Top management provided political commitment and direction and demanded accountability; middle management, which had political, policy, and programmatic skills, guided the detailed planning and worked to ensure all stakeholders were listened to and heard; and technical management was responsive. Communication and listening were essential to foster trustas could be seen in the joint school health committees.

As the latter example demonstrates, collaboration alone, however, was not sufficient. Other important and mutually reinforcing elements included: evidence-based planning and implementation, efforts to build trust and credibility, and strategic communication and innovative use of mass media.

The researchers indicate that longer-lasting benefits may have emerged from the collaborations established during the different phases of Malaysia's HPV programme. These have their roots in the specific underlying principles of the collaborations, including providing forums to facilitate formal communication and agreements, familiarity and trust, and strengthened stakeholder satisfaction and empowerment. The MoH has presented its experience of the HPV programme in many regional and global conferences since 2010. Staff of the programme also provided inputs to a 2017 World Health Organization (WHO) publication on HPV vaccine communication and engaged in a study tour in 2011 with staff of the MoH of Brunei to share their experiences.

The value of providing HPV immunisation in boys is increasingly recognised. Closing this gap in coverage is a challenge, and collaboration between sectors may again prove valuable in efforts to reach these groups in Malaysia.