Stakeholders' Understandings of Human Papillomavirus (HPV) Vaccination in Sub-Saharan Africa: A Rapid Qualitative Systematic Review

"This review iterates the importance of first working with communities to gauge local and context-specific understandings, before trying to implement change through one-size-fits all education, sensitization and behavior change strategies."

Despite a steady rise in the number of countries in Sub-Saharan Africa (SSA) introducing human papillomavirus (HPV) vaccination into national immunisation programmes and demonstration/pilot projects, coverage is still suboptimal. Persistent skepticism around HPV vaccination has contributed to stakeholder uncertainty and actual decision making around the HPV vaccine. This low uptake is worrisome in light of high rates of cervical cancer and other cancers caused by this sexually transmitted disease in Africa. In order to complement existing research and to inform HPV vaccination implementation approaches, this systematic review explored qualitative literature documenting the perspectives of adolescents, parents and caregivers, teachers and healthcare providers, and political, community, and religious leaders in creating demand for HPV vaccination in SSA.

During March and April 2019, the researchers 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 259 articles. Thirty-one studies were found eligible for inclusion (e.g., studies conducted in SSA and published in English from 2006 - present). The researchers analysed the 31 studies thematically and assessed their quality.

The majority of included studies came from Eastern and Southern Africa. All of them used focus group discussions or interviews (or both) to collect data. Thematic, comparative analysis, narrative synthesis, grounded theory, and content analysis were the four methods of data analysis across studies.

Three major themes emerged from this analysis:

1. Knowledge of HPV vaccination and cervical cancer is intertwined with misinformation - For example, delayed health-seeking behaviour in SSA, coupled with a lack of knowledge about the preventative nature of HPV vaccination, contributed to stakeholders' (mis)understandings of cervical cancer and the HPV vaccine across studies. There were significant social layers of influence on stakeholder perceptions about HPV vaccination, as HPV vaccination behaviours, actions, and attitudes are shaped by both exposure to information and interaction with fellow community members. In particular, political leaders, religious figures, community leaders, community elders, healthcare providers, teachers, and peers contributed to local behaviuors and understandings related to HPV vaccination. Misinformation was perceived to be perpetuated in communities in different ways; for example, Nyambe and colleagues attributed persistent misinformation in Zambia to low levels of social mobilisation around HPV vaccination.
2. Fear has shaped contradictory perceptions about HPV vaccination - Fear of infertility was the most salient theme in stakeholders' narratives about cervical cancer and HPV vaccination. Male and female stakeholders placed significant value on a woman's ability to bear children, which means that infertility is highly stigmatised and seen as a source of shame. Some believed infertility was a result of cervical cancer, while others believed infertility was a result of receiving the HPV vaccine. These contrasting perspectives contributed to differing HPV vaccination behaviours. The debate around the cause of infertility was further fueled by distrust of both local health systems and governments, as well as international vaccine initiatives and stakeholders from high-income countries, who were perceived to be drive the rollout of HPV vaccination in some studies.
3. Gender dynamics are relevant in how stakeholders understand HPV vaccination in SSA - As HPV is a gender-neutral virus, several stakeholders were confused by HPV vaccination being solely directed at females (the so-called "feminisation" of this vaccine). Accordingly, some male stakeholders expressed disinterest in HPV vaccination, assuming that since it is a female-directed vaccine aimed at addressing cervical cancer, HPV must not affect men. Health-seeking behaviour was also shaped by gender dynamics. In some countries, men had the ultimate say in women's health decisions, including decisions around HPV vaccination. In general, male and female stakeholders across studies urged men to be more included in education around cervical cancer and HPV vaccination. Greater male involvement could not only help them understand the vaccine's importance for their own health but help reduce stigma around HPV vaccination, which has been seen as a female responsibility and health issue.

In short, the review found that stakeholder understandings of HPV vaccination in SSA are shaped by a complex relationship between knowledge and misinformation, fear of infertility, and social and gender dynamics. The findings may have practical implications for how demand for HPV vaccination might be enhanced, including:

• The dynamics of trust and drivers of distrust between communal stakeholders and the government, medical, and public health communities need to be recognised and addressed. Prior to vaccine rollout, education and social mobilisation around HPV vaccination programmes should engage communities in order to gauge local understandings, conceptions and misconceptions, and baseline perceptions and fears around cervical cancer, HPV, and HPV vaccination.
• Engagement with and involvement of various social actors identified as trusted sources of information from the community themselves may facilitate improvements in stakeholder perceptions of HPV vaccination in SSA. The researchers suggest attending to local language nuances when creating content and developing education and awareness-raising interventions.
• Implementation of HPV vaccination programmes without thorough understanding of gender dynamics within the context of the specific country implementing HPV vaccination can perpetuate confusion, misinformation, distrust, and stigma - thereby potentially creating roadblocks for HPV vaccination uptake. This is notable, as the review found that, depending on the country, health-seeking behaviour and decision making around HPV vaccination were driven by either male or female heads of households, suggesting that locally appropriate interventions need to address country-specific gender dynamics in health seeking behaviour.

In conclusion: "This review provides a 'big picture' demand-side perspective to contribute to improvements in current and future HPV vaccination strategies in SSA, an under-researched area overall."