Advocacy, Communication, and Partnerships: Mobilizing for Effective Widespread Cervical Cancer Prevention

"If we can foster sufficient political will, forge links with global health initiatives, and ensure that decision-makers and the public have accurate and realistic expectations of the services, elimination of cervical cancer is within reach. Clear and sustained communication, robust advocacy, and strategic partnerships are needed to inspire national governments and international bodies to action.."

Guidelines, conceptual frameworks, manuals, and lists of best practices in advocacy and communication abound, including some specifically on cervical cancer. Rather than summarising the literature in depth, this paper seeks to provide a snapshot of the global cervical cancer advocacy and communication environment in 2017, with a special focus on networks and coalitions. The recommendations at the end of the paper suggest activities that ministries of health and non-governmental organisations (NGOs) can undertake, and donors can support, to increase political will and public demand for expanded cervical cancer prevention services.

National immunisation programmes in 74 countries offer human papillomavirus (HPV) vaccination, including countries in Africa, Asia, and Latin America. That said, only an estimated 3% of eligible girls have been vaccinated in low-income countries, and many ministries of health have not yet added the vaccine to their routine immunisation programme. In addition to challenges of funding and policy, there are other significant barriers to tackle that are explored in the article, such as resistance to new solutions (familiarity with Pap tests, confidence, or profit, for instance). Behavioural challenges, such as hesitancy to be vaccinated, are shared by other health programmes such as polio elimination and hepatitis B immunisation. Misinformation on the internet, negative media reports, anti-vaccination activism, and distrust of the medical establishment contribute to such barriers. Social stigma about cancer and reluctance to discuss reproductive health in general - along with, in some settings, lack of women's empowerment and/or a culture of machismo - create additional barriers.

However, as reported here, progress in several areas bodes well for improved access to cervical cancer prevention in the coming years. In 2012, Gavi, the Vaccine Alliance began supporting the introduction of HPV vaccination in the lowest-income countries in the world. In part, that decision was based on advocacy efforts, including documentation of demand for cervical cancer prevention in Africa, Asia, and Latin America. "Uptake has been impressive..." Other strategies related to partnership are outlined and include, for example, the fact that, as of 2016, there were 11 active, global or regional, cervical-cancer-specific coalitions (see Table 1) and many nationally focused partnerships. An important goal of the coalitions is to integrate cervical cancer prevention into existing programmes that routinely impact women's health. Pink Ribbon Red Ribbon is an example of a multisector partnership seeking, among other things, to integrate breast and cervical cancer screening into HIV/AIDS programmes.

More specifically, partnerships are described here as crucial for amplifying the advocacy and communication efforts of individual member organisations and also enabling members to combine technical and other resources to jointly pursue a common goal. Advocacy and communication can be thought of as drivers for increasing the visibility of a health issue on the global level, while also stimulating national uptake and community demand. Both aim to change behaviours, and the two terms can describe many different types of activities, focused on a variety of objectives. The authors identify the following as key advocacy and communication tasks: (i) building awareness about cervical cancer and how it can be prevented; (ii) mobilising investments in cervical cancer programming, including highlighting links with national health and development priorities; (iii) updating policies to support services and scale-up; (iv) responding to misinformation and addressing hesitancy to be vaccinated or screened; (v) creating individual and community demand for services; (vi) reducing stigma associated with cervical cancer; and (vii) encouraging partnerships and collaborative effort. On the latter, partnerships have been shown to be most effective when members represent a variety of constituent organisations, e.g., governments, multilateral organisations, professional associations, universities, NGOs, and cancer survivor and other community groups. To the extent possible, for maximum impact, they also should embrace multisectoral causes such as reproductive health and women's empowerment.

"Based on experience with advocacy and communication programs to date, the authors propose the following interventions aimed at increasing access to prevention services.

1. Continue to expand partnerships, and use these networks to advocate globally, regionally, and nationally for resources to ensure equitable access to cervical cancer programs for all girls and women. Include professional societies and women's groups.
2. Speak with a unified voice to increase demand, articulating technically accurate, clear, and emotionally engaging messages. Develop audience-specific messages, including arguments expressly designed to appeal to policy makers...
3. Advocate for global and national targets for prevention coverage....Demand levels of resources that will lead to elimination by 2030.
4. Work with ministry of health partners to include cervical cancer prevention in applications to the Global Fund and other funding mechanisms.
5. Increase awareness of the disease and the potential for prevention and elimination by providing evidence-based information about cervical cancer prevention and addressing misconceptions and misunderstandings. Encourage women and their families to seek screening and vaccination services and to follow up on treatment.
6. Organize outreach beyond the cancer community - to women's rights and reproductive health activists, for example. Work with advocates in the HIV/AIDS and reproductive health communities to broaden the message and reach. Consider recruiting highly visible and credible champions like women sports figures, musicians, actors, and leaders.
7. Build cervical cancer advocacy and communication capacity in lowincome countries for both government and NGO staff."

The authors also argue that "[s]cientific evidence about the promise of prevention must be 'translated' for various audiences, ranging from national decision-makers, to service providers, to parents and school children." They conclude: "Advocacy and communication interventions can help overcome barriers to increased access to prevention services, especially when implemented through strong partnerships speaking with a common voice."