Adolescent Girls' Recommendations for the Design of a Human Papillomavirus Vaccination Program in Sindh, Pakistan: A Qualitative Study

"Although several countries successfully rolled out HPV vaccination programs,...program design and evaluation have rarely included adolescents' perspectives..."

In Pakistan, cervical cancer is the third most frequent cancer among women and the third leading cause of female cancer deaths. Vaccination of adolescent girls against human papillomavirus (HPV) significantly reduces the incidence of cervical cancer. HPV vaccination is available in Pakistan but is not yet included in the national immunisation schedule. This formative study explores adolescent girls' knowledge and perspectives on HPV and cervical cancer and collects their recommendations for implementing an HPV vaccination programme in their community.

Using a qualitative exploratory study design, the researchers conducted 4 focus group discussions (FGDs) with 12 unmarried girls aged 16-19 years per group in District West, Karachi, Sindh province, Pakistan. The study focused on seeking only girls' perspectives, given they will be the primary population included in the country's planned HPV vaccination programme.

Findings are presented, illustrated with quotations from participants, in the areas of:

• Knowledge: 96% of the girls harboured specific misconceptions regarding the mode of transmission of HPV, and 42% had never heard of a uterus or cervix before this study, even though age- and culture-appropriate language was used.
• Risk perceptions: All the girls perceived cancer as a severe disease, though 81% were unable to correctly identify risk factors of cervical cancer.
• Information sources: Participants mentioned numerous sources for information on HPV vaccination. Girls' preferred sources were either doctors (69%) and nurses (12%) or individuals who are already part of their everyday life (e.g., family: 46%). When choosing information delivery channels for the dissemination of information on the HPV vaccine to the broader community, girls considered accessibility to be a key factor. For instance, 17% of the girls regarded internet not be appropriate as the main source of information, because "most people don't have access to it". TV may not be a good medium to spread information specifically related to HPV and cervical cancer because "news and TV is mostly watched by male members".
• Vaccination decision-making: Mothers (81%), sisters (19%), and other female relatives (21%) were indicated as girls' preferred point of contact for discussions related to HPV and cervical cancer. However, fathers (50%) were generally portrayed as the definitive decision-making authority with regard to vaccination. Elderly family members, according to 31% of the girls, can also play a crucial role.
• Vaccine hesitancy and refusal: 56% of participants indicated vaccine hesitancy as the most likely obstacle to successful implementation of an HPV vaccination programme. Girls anticipated that parents, and fathers in particular (33%), may hesitate to provide consent to HPV vaccination for their daughters, and some (17%) expected their parents would not agree to vaccination "by any means". Fear of vaccination side effects and similar misconceptions including cosmetic issues (10%), such as a "scar mark on [girls'] hands" were highlighted as key reasons. Girls attributed the spread of these misconceptions to the general lack of information on vaccination among parents (27%), as well as the circulation of negative rumours about vaccines in their community (49%).
• HPV vaccine educational campaign: 60% of the girls suggested that a multi-channel, community-based educational campaign should be implemented alongside the HPV vaccination programme, with 17% of the girls recommending that the campaign should seek to reach the entire community. Their proposed educational campaign included peer education, and they often carved out a role for themselves as information messengers for their family. Half of the girls believed community-based polio workers could also play an important role: "When they go for polio vaccination, they will spread HPV information as well".
• HPV vaccination programme implementation: 42% of the girls recommended household visits in the community to identify eligible individuals, because this approach would foster the inclusion of girls who do not attend school or are otherwise marginalised. To ensure accessibility, 60% of the girls believed vaccination itself should then be offered at community-based camps; notably, Pakistanis are accustomed to mass immunisation campaigns (e.g., for polio) and outreach activities in the community around vaccination. Such community-based vaccination may also encourage vaccination uptake among those who do not trust vaccinations at healthcare facilities. However, 44% girls suggested that the vaccine should be administered by a doctor in the presence of girls' parents or other adult family members. 
• Trust: Girls' suggestion to identify eligible individuals through household visits was linked to the goal of building a trustful relationship with parents before inviting girls to be vaccinated. Trust also emerged as a key asset to persuade parents to provide consent and to maintain high schedule completion rates among girls. Overall, the researchers stress the importance of building a solid foundation of trust between girls' families, programme managers, and other stakeholders. They note, however, that "determinants of trust may vary across epidemiologic conditions, cultural norms, and socio-political environment....More in-depth research is needed to better define the nuances of trust in the local context and build resilience against factors potentially undermining it over time."

Thus, this formative research helped develop a set of context-specific recommendations for the implementation of an HPV vaccination programme in Pakistan reflective of adolescent girls' perspectives. The following strategies are being explored: establishing trust with vaccine providers, increasing accessibility of vaccinations and vaccine-related knowledge through community-based informational campaigns and vaccination camps, and informing key decision-makers in the family, particularly fathers, of the long-term benefits of HPV vaccination to counter vaccine hesitancy and refusal.

"Future research efforts could be directed toward interviewing parents and caregivers to understand their perspectives and perceptions around the HPV vaccine, and further investigate the possible reasons and remedies for vaccine hesitancy."

In conclusion: "integrating adolescents' recommendations when developing a health intervention that is directly relevant to them may help to design a well-targeted program, implemented more effectively in the local context."