By Beryne Odeny (Washington University in St. Louis, Department of Surgery) and Julia Robinson (PLOS Global Public Health) The first in-person CUGH…
By guest contributors Jessica Posner and Nicole Castle
“The HPV vaccine has a vital role to play in preventing cervical cancer. We must act now to scale up cervical cancer prevention and control strategies and ensure girls everywhere know that they can benefit from its lifesaving impact.” – Anuradha Gupta, former Deputy CEO of Gavi
This October 11th is the 10th anniversary of the Day of the Girl Child, a day dedicated to recognizing girls’ rights. Many girls around the world continue to experience often insurmountable challenges to fulfill their rights as outlined in the Convention on the Rights of the Child. In the past nearly three years the COVID-19 pandemic has measurably worsened the right of girls to health. In 2021, WHO and UNICEF recorded the largest sustained decline in childhood vaccination in 30 years with over 25% of the coverage of human papillomavirus (HPV) vaccines that was achieved in 2019 globally lost. Global coverage of the first dose of the HPV vaccine is only 15%, and there is much work to be done to protect girls and women.
In 2020, cervical cancer (most often caused by HPV) killed more than 342,000 women; 90 percent of these deaths occurred in low- and middle-income countries (LMICs). The HPV vaccine is the most cost-effective public health measure to prevent HPV infection and subsequent development of cervical cancer when given to girls between the ages of 9 and 14 years old. While we know that the HPV vaccine is foundational to cervical cancer prevention, there are significant inequities in access and uptake across countries. Not only is the rate of vaccine introduction higher in high-income countries (HICs) compared to LMICs, but the coverage rate is also higher. In 2019, first dose coverage in HICs was estimated to be 50%, while in LMICs estimated coverage was only at 16%.
What are the challenges to HPV vaccine uptake?
Cultural norms and gender biases: The optimal age of vaccination coincides with a key transitional period in a girl’s life, not only for herself, but also in how the world views her as she becomes sexually active. The intersection of sexual stigma and gendered power dynamics during this critical prevention period are significant barriers. In some school-based HPV vaccine delivery programs, vaccination requires “opt-in” rather than “opt-out” consent, which requires caregivers to provide written consent or accompaniment to vaccination. Obtaining “opt in” consent from caregivers who do not want their daughters vaccinated is challenging. The ability of girls to travel independently for facility-based vaccinations and expectations for girls’ engagement in domestic work serve as additional barriers to vaccination. Studies demonstrate the power of faith communities to spread misinformation that discourages HPV vaccination to parents and health professionals, suggesting that it encourages girls to have premarital sex. Community cultural and religious beliefs about vaccination also negatively impact perceptions of the HPV vaccine.
Unidentified and out-of-school girls: Many out-of-school girls live in places that are challenging for the health system to reach, including girls who live in low-income settlements, rural remote areas, and those who are nomadic or semi-nomadic. Most girls do not have scheduled check-ins for routine health screenings which means they are often invisible to the health system, especially during these important years before they are sexually active, which are the most critical for HPV vaccination. This creates significant challenges to plan HPV vaccine roll-out for a population that has not been estimated or mapped. Calculating coverage percentages is particularly challenging when the denominator is unknown for these age groups, resulting in limited understanding of the reach and impact of the program and what is left to do.
Limited knowledge of HPV: One of the largest contributing factors to low HPV vaccine uptake is limited knowledge of cervical cancer and the role of the HPV vaccine in its prevention among community members including factually incorrect safety concerns. A knowledge, attitudes and practices study in Kenya found that low knowledge levels were correlated with increased likelihood of vaccine refusal. Studies on HPV vaccine misinformation on social media have found that factually correct information is more likely to result in vaccine uptake.
Health system challenges: Costs associated with HPV vaccine procurement and roll-out are significant and require commitment on the part of governments to prioritize girls from a financial perspective. Health systems disruptions from COVID-19 have not spared immunization services/schedules and have resulted in delays of what were regularly scheduled, routine vaccines. School closures during the pandemic disrupted vaccination, including against HPV, in many countries due to inability to deliver vaccines in school and reduced health care worker availability. National planning efforts will need to dedicate additional resources and vaccines to vaccinate girls who were missed as a result of the disruption.
HPV vaccination uptake is influenced by a myriad of sociocultural and health systems challenges that are highly nuanced based upon each girl’s context. Our global experience supporting HPV vaccine introduction has taught us that person-centered care approaches hold real potential to overcome these challenges and to make measurable progress for girls everywhere to achieve their right to health. Figure 1 provides a synthesis of our global learnings on specific activities that strengthen person-centered care for HPV vaccination rollout and adoption.
Our Call to Action
Given the disproportionate rates of cervical cancer among girls in low and middle income countries and the body of evidence that demonstrates the efficacy of the HPV vaccine, we have a moral imperative to act now. Our call to action emphasizes building person-centered approaches that overcome the unique challenges that girls in LMICs encounter to access the HPV vaccine.
- For our girls: Girls should be active participants, not passive beneficiaries in the design and roll out of any intervention. This requires inclusive approaches that harness the knowledge of diverse girls who can provide guidance on how to reach their peers in diverse settings. We should also build the skills of girls to advocate for themselves and their bodies, communicate with their parents around the HPV vaccine and to provide peer-to-peer engagement.
- For our leaders: Design adolescent-friendly services that center girls’ needs through creating positive experiences for girls and their families within the health system. This includes building HCW skills to offer services free of stigma and discrimination.
- Make the HPV vaccine more accessible through integrating it into other pre-adolescent and adolescent health services where they are available such as nutrition programs, HIV treatment, and sexual and reproductive health.
- Think outside of the box to reach the most marginalized girls who are not found in health facilities and schools. This may include community outreach campaigns in remote areas, markets, places of worship, and peer-based approaches. This may require creative collaboration with Ministries of Education, the private sector, traditional healing networks, and social media to meet girls with their preferred form of messaging and in the most convenient location for them to access the HPV vaccine.
- Community and faith leaders should be educated and empowered to disseminate accurate and destigmatizing messaging on HPV vaccination to reach parents and girls.
- For our HCWs: Strengthen the design of interpersonal communication trainings so that it is tailored to context and can meet the needs of girls and their caretakers. As HCWs are the most trusted source of information, their interactions with the community are critical to improving the uptake of vaccination.
- For our health systems: Ensure that health systems can accurately estimate and locate eligible girls and that services can reach them where they are. This requires an investment in building the skills of HCW to design, implement and monitor a comprehensive strategy that includes fixed, outreach and potentially, mobile services.
About the authors:
Jessica Posner is currently the Strategic Information Lead for the Center for HIV and Infectious Diseases at JSI. She has a master’s in public health from Tulane University’s School of Public Health and Tropical Medicine. Through her work at JSI (@JSIhealth) she has worked with organizations both in the US and abroad, as well as governments and donors. Jessica is 43 years old and is a mother of twin girls, a wife, sister, daughter, aunt, and a feminist. She currently resides in Washington, DC.
Nicole Castle is a Social and Behavior Change Technical Officer at JSI. She works across teams to support the application of behavioral science to global health and development programs. Nicole earned her MSc from the London School of Economics and Political Science and has a background in the social sciences. Her Twitter handle is @nrdcastle.