Promoting Adolescent Health through Integrated Human Papillomavirus Vaccination Programs: The Experience of Togo

"The experience gained from this demonstration program is valuable in assessing possibilities for integrating vaccination and adolescent health interventions in Togo, as well as in other countries of the subregion, the African continent and beyond."

In 2012, Gavi, the Vaccine Alliance, launched its human papillomavirus (HPV) vaccine demonstration programme in countries in Africa, Asia, and Latin America. The global health community recognised the prospect of this vaccine not only for the prevention of cervical cancer but also as a way to concurrently and synergistically deliver health interventions to an age group that historically had limited access to healthcare services. This paper reviews the efforts undertaken by the government of Togo to integrate adolescent health programming with the HPV vaccination roll out - making suggestions as to how this experience can inform future integration efforts.

With the support of partners (Gavi, WHO, UNFPA, and the United Nations Children's Fund - UNICEF), Togo completed, in 2017, two years of an HPV vaccine demonstration project, which entailed vaccinating 10-year-old girls against HPV in Golfe and Tchamba districts and integrating a health education component focused on puberty education/menstrual hygiene and handwashing practice. Carried out after the HPV vaccinations in the schools visited, the 15- to 25-minute education sessions were designed for both girls and boys aged 9 to 13 years. Prior to the sessions, a pre-test of the key messages and materials was carried out, and cascading trainings for participating health facilities staff were held. With the support of UNFPA, 900 posters were produced and displayed in schools on the basis of one poster per topic area, and 100 copies of laminated A4-format materials were produced to help health workers convey the messages to the students. A total of 874 schools were involved in HPV vaccination and related health education activities, reaching 98,042 students in the two districts.

The post-implementation programme evaluation used mixed methods to assess feasibility and acceptability of the integrated adolescent package of care. Evaluation sites were selected from within Golfe and Tchamba and from two comparator districts that had not taken part in the demonstration programme, matched for geography and demographics. Programme monitoring data were used to capture quantitative service delivery measures. Questionnaires and discussion guides for semi-structured interviews and focus group discussions were developed and pretested prior to the study.

The study showed that the HPV vaccination programme demonstrated high coverage (of the 15,272 girls expected for the 2nd dose, 13,875 were vaccinated, or nearly 91% vaccination coverage) and acceptance. The majority of teachers (93%) from the surveyed schools confirmed that virtually all students from the targeted classes participated in health education sessions on handwashing and puberty education. The majority of healthcare workers (75%) and teachers (77%) involved in the project said that the tools used for health education were appropriate. Most of the students were able to easily understand and comment on the posters used and could correctly identify the key messages they conveyed. The intervention saw a high degree of engagement and satisfaction by the students themselves.

Nearly two-fifths of adolescents interviewed were able to spontaneously recall sexual and reproductive health (SRH) messages they had heard during their session. When prompted, three-quarters of adolescents were able to recall SRH messages. "Message recall has been associated with behavior change in the family planning field."

Furthermore, teachers said the health education sessions carried out as part of the HPV vaccine roll out initiated a concrete change in behaviour in terms of hand washing. One teacher commented, "Most of the time they [the students] wash their hands regularly before eating and after using the restrooms. This was not the case before the awareness raising". Another said the students "even organized themselves by class for handwashing sessions and a group was created to go and continue the sensitization on reproductive health".

However, interviews with parents showed that many of them had poor awareness of the HPV vaccination campaign and the health education sessions. Parental consent was implied, and no unified protocol was in place to inform parents about either the immunisation activity or the health education component. Despite this, most parents were aware of cervical cancer and the protective effect of the HPV vaccine. Some reported they discussed the benefits of the vaccination and the health education messages with their children.

Reasons in favor of integration given by the health workers and teachers included the achievement of two objectives in one action, the fact that both vaccination and health education aim at improving young people's health, and the fact that through this integration health education is followed up by the provision of a health service (in this case, vaccination). For those who raised concerns regarding the feasibility or acceptability of the integration process, the main issue mentioned was a lack of time. The fact that not all students, including all the boys, who participated in the health education sessions were eligible for vaccination was seen as an additional complicating factor.

That said, all surveyed healthcare providers felt that the health education sessions should be carried out in other districts and regions of Togo and deemed it a good idea to continue these health education sessions during future vaccination against HPV. Due to supply shortages of the country's preferred vaccine choice (Cevarix), Togo postponed national introduction of the HPV vaccine from 2021 to 2023. It remains to be seen if and how the stakeholders will prioritise this integration effort in the national HPV vaccine roll out.

In conclusion: "In the context of Togo, HPV vaccine implementation represents an opportunity to start a dialogue with young adolescent girls and boys and impart accurate information about the emotional and sexual life of young people, prepare young girls for the beginning of their menses, work with boys and girls on concepts of gender equality, respect and consent and help young adolescents make informed choices in terms of sexual and reproductive health." However, the researchers suggest that more operational research is needed to understand how to increase the impact and sustainability of the co-delivery of interventions.