Factors Involved in Human Papillomavirus (HPV) Vaccine Hesitancy Among Women in the South-East Asian Region (SEAR) and Western Pacific Region (WPR): A Scoping Review

"[I]nsight into the common reasons why women refuse HPV vaccination will help inform the development of strategies to improve vaccine uptake in LMICs."

Countries of the South East Asia (SEA) and Western Pacific (WP) regions are mostly made up of low- to middle-income countries (LMICs), representing a population highly at risk of cervical cancer. Human papillomavirus (HPV) immunisation programmes and educational campaigns differ markedly across countries, and there have been concerns on rates of vaccination uptake since its licensure in 2006. Hence, the objectives of this article are to: (i) systematically review influencing factors predicting HPV vaccine acceptability among women in SEAR and WPR; (ii) provide a summarised literature of evidence on these factors; and (iii) offer recommendations for improving HPV vaccine acceptability and addressing barriers identified in the review.

A total of 63 primary research studies were included for review, with publication dates ranging between 2006 and 2016. As echoed by findings from international literature, a woman's decision-making process is influenced by a myriad of factors. Irrespective of a country's income status, cervical cancer mortality rates, and HPV immunisation programmes, the influencing factors that arise when a woman decides to obtain the vaccine were similar in both SEAR and WPR, as well as other countries at an international level. Some specific findings:

• The cost of the HPV vaccine is a significant barrier among women in both SEAR and WPR, as demonstrated by the reluctance of most women to pay for it themselves. As expected, financial concerns were a more profound barrier in women from economically poor families or rural residence.
• Irrespective of the participant's sociodemographic and geographic background, most included studies reported that women's knowledge of HPV and awareness of its symptoms and prevention were cursory in SEAR and WPR.
• In SEAR and WPR, regardless of study setting and geography, women had concerns on the side effects of the vaccine, which stemmed from doubts about its safety and efficacy. (However, studies have shown that allergic reactions are actually extremely rare.)
• A low perception of contracting HPV infection and cervical cancer was evident among young women and female parents in both SEAR and WPR, resulting in a lack of urgency to receive HPV vaccination. It is possible that these women do not understand the risk factors that can lead to HPV infection.
• Young women and parents in both SEAR and WPR consistently cited healthcare providers as a trusted source of information on HPV vaccination. Thus, physicians and other healthcare professionals should be prepared to provide strong recommendations to their patients on the benefits of HPV vaccination and to assure the public that any side effects are treatable.

The review found that most adult women received HPV-related information from media sources, largely from television, newspapers, and magazines. Adolescent girls, on the other hand, tended to receive HPV-related information from their respective schools or teachers. Hence, to improve health literacy levels on HPV infection and vaccination, it is suggested that a school-based education programme for HPV could help improve awareness and knowledge among young adolescent girls. In comparison, mediums such as television, magazines, and newspapers will be effective in promoting knowledge on HPV infection to the general public. In addition, it is recommended that pamphlets on HPV vaccination be made available in clinics and hospitals to help motivate the public to make enquiries on HPV vaccination.

"In summary, women in SEAR and WPR are unable to make informed decisions due to severe knowledge deficits on HPV-related aspects. This is evident from their request for more information, poor knowledge and awareness, low perceived risk of acquiring cervical cancer, and a preoccupation with the occurrence of side-effects with HPV vaccination. Lack of communication between healthcare providers and young women or parents on HPV vaccination could also explain the low uptake of the vaccine in the targeted population. Cost of the HPV vaccine is also a significant barrier among women in settings where they have to pay for the vaccine themselves."