Overcoming Barriers in HPV Vaccination and Screening Programs

"When dealing with HPV vaccine confidence it is necessary to identify if and where pockets of vaccine hesitancy exist, to monitor public confidence, to develop an understanding of scope/context/root causes of vaccine hesitancy, and to use context-specific, evidence-based strategies (including, but not limited to, communication) to address underlying issues."

The globally focused HPV [human papillomavirus] Prevention and Control Board was created with the aim to share relevant information on HPV with a broad array of stakeholders and to implement preventive strategies to reduce the HPV-related disease burden. This article reports on the discussion that took place during its first official meeting, held June 27-28 2016. The objectives of the meeting were to: (a) summarise the available adverse event profile and any reported safety concerns following HPV vaccination, (b) summarise cultural, perceptual, infrastructural, and financial barriers to the implementation of vaccination, (c) identify factors that influence adherence to cervical screening programmes, (d) propose strategies to build public confidence in HPV prevention programmes and address any vaccination and screening hesitancy, and (e) discuss new approaches to improve HPV prevention and cervical cancer control. The below summary focuses on communication-related elements of the discussion.

Experiences from a number of countries were discussed; a SWOT (Strengths, Weaknesses, Opportunities and Threats) analysis of all countries combined is presented in the article. Selected findings:

• Many countries utilised strong evidence-based recommendations prior to the introduction of the HPV vaccine and were able to conduct well-coordinated immunisation and communication campaigns. Those countries that included school-based programmes generally had higher coverage. Nevertheless, some countries, such as Japan and Denmark, experienced high initial uptake using a community-based programme. The use of institutional and social media to spread awareness was considered a strength.
• Weaknesses in HPV vaccine programmes are frequently due to low initial vaccine uptake, the extended time period between vaccine introduction and potential impact on clinical endpoints, insufficient data infrastructure to determine population-level vaccine effects and contextualised perceived vaccine risks, and sub-optimal communication regarding the vaccine. In some countries, the lack of vaccine advocates and the social taboo of sexuality in adolescent girls have impeded communication related to HPV risk and vaccine awareness. In other countries, advocacy with the media and community leaders has reinforced awareness around the impact and seriousness of cervical cancer. The increased public concern about cervical cancer following the death of a celebrity is likely to increase awareness, as has been seen in Denmark, England, and Scotland. The political commitment of the Belgian government towards vaccination as a public health goal was also seen as an opportunity for strengthening local HPV vaccine programmes.
• In all countries, the presence of anti-vaccination campaigns, usually well-organised and very active, is seen as the biggest threat to HPV vaccination programmes, especially as concerns voiced on the internet or case stories can be seen by the public as evidence against the vaccine. The perceived association of the vaccine with HIV (and the social stigma attached to this infection) and the idea that vaccination may be used to control fertility are both specific threats in India. An unrestrained media environment and the lack of response from the government to the anti-vaccination campaigns are threats to the HPV vaccination programme in Japan. The lack of a strong provider recommendation to vaccinate against HPV was seen as a threat in the United States (US).

The Board looked in depth at wavering vaccine confidence, an issue they describe as "a global phenomenon with deep local roots. The history of public questioning of vaccines is as old as vaccination itself, but the speed and scope of any global spread of public concern is quickly changing due to the influence of rapid and wide-reaching communication channels, such as the Internet, television and social media." Determinants of HPV vaccine confidence differ from those of other vaccines; these determinants also differ between cultures. Thus, as the Board articulated, confidence in HPV vaccine should be measured by qualitative and epidemiological research, using for instance the open-ended questions developed by the Strategic Advisory Group of Experts (SAGE) or the Parent Attitudes About Childhood Vaccines survey. Internet surveys and media tracking can provide fast data; global news media monitoring on HPV vaccines is ongoing at the London School of Hygiene & Tropical Medicine.

The article goes on to examine approaches for dealing with HPV vaccine hesitancy, providing an example of a communication and education initiative carried out around HPV Vaccination in Scotland. Among the suggestions for other programmes: to start communication planning early, allowing for formative research to anticipate difficult issues and building cross-sectoral team to integrate all relevant sectors. Choosing channels that adolescents and their parents identify with and trust is important. The roles of teachers/administrators, general practitioners (GPs) and other health care professionals, and the media in communicating effectively about HPV vaccination are discussed. Regarding the latter group, the Board feels that it is essential to provide the media with accurate information (e.g., by organising pre-campaign briefing sessions for journalists) so that they are less likely to report misinformation from other sources.

Table 1 offers guidance on best practices for communication, which are, in brief:

• Capitalise on every communication opportunity - even in informal ways, e.g., a short message at a concert by a singer popular with adolescent girls.
• Develop a frequently asked questions (FAQ) reference guide. This could be housed on a dedicated website where any audience can access up-to-date evidence-based information and materials.
• Use language and materials girls can relate to and have fun with, e.g., colourful materials with modern designs. In countries where text messaging is common, there may be opportunities for text-based quizzes and games.
• Use gain-framed messaging (i.e., promoting the benefits of vaccination), rather than emphasising the consequences of not getting vaccinated. Build on positive perceptions of vaccines to promote vaccination and minimise stigma.
• Set up a telephone hotline so that girls, parents, and others can have a real conversation with an expert about HPV vaccine.
• Use a mix of channels, including schools, health workers, churches, radio and television, and the internet and social media (e.g., Facebook or Twitter accounts devoted to adolescent health, including HPV vaccine).
• Pay attention to underserved populations in order to promote equity - e.g., the majority of Roma women and other disadvantaged groups of women are rarely screened.

One section of the document goes beyond what was said at the meeting through a look at the literature. For instance, although not extensively discussed during the meeting, the Board points out that advisory groups and governments can play an important role in communication. As indicated by the example of Scotland, well-planned, -designed, and -coordinated communication can promote screening and vaccination programmes in a relevant and effective way.

In conclusion: "It is imperative that HPV vaccination programs and cancer prevention programs proactively provide up-to-date information on benefits and risks of vaccination to ensure that confidence remains high....[T]he success of a national vaccine program requires...: careful planning including attitudinal work, well in advance of the start of the program; good communication, with all parties involved, with material that is suitable for each target group, and extra attention for hard-to-reach populations, as they may be at higher risk; delivery of the vaccine through a school-based system; an action plan to quickly and effectively handle anti-vaccine media alerts; and appropriate data management and linkage to facilitate early detection of signals, but also show impact of vaccination."