Features of Human Papillomavirus Vaccination Education Strategies in Low- and Middle-Income Countries: A Scoping Review

"Future HPV educational strategies should use intersectional theoretical frameworks to analyze the... complex individual and social factors that influence access to inclusive HPV information and HPV education strategies."

Of the 20 countries with the highest burden of cervical cancer worldwide, 19 of them are from Sub-Saharan Africa (SSA). Uptake of the human papillomavirus (HPV) vaccines that prevent these and other HPV-related cancers remains low. Thus, effective HPV educational strategies will be crucial in preparing stakeholders for national HPV vaccination programmes when they are implemented in many SSA countries. This scoping review aimed to describe studies on HPV vaccination education strategies from low- and middle-income countries (LMICs) that could be applicable to SSA.

A search of four electronic health sciences databases for relevant reports published between January 2006 and January 2021 retrieved 1,757 reports, of which 48 were from LMICs (originating from 37 countries, representing less than one-third of the 137 LMICs). Most of the reports (79.2%, n = 38) included in this review were quantitative designs, with few qualitative studies (12.5%, n = 6) and fewer mixed-methods designs (8.3%, n = 4). ("An expanded qualitative exploration of HPV educational strategies can offer a contextual understanding of what works and what does not work in each unique context within LMICs.") Less than one-fifth of the studies (n = 9) reported a theoretical basis for their strategies. Most studies (54%, n = 26) were published between 2018 and 2020.

There were 39 interventional studies (81.3%). Of these, 32 (82.1%) were individual or group-level interventions addressing specific populations (e.g., adolescent girls, parents). Six (15.4%) studies were multilevel interventions reaching out to multiple population groups (e.g., parents, teachers, and adolescents) and including community or institutional approaches (e.g., unions, schools, workplaces, etc.). One study was a system-level intervention that focused on a large-scale pilot HPV vaccination programme. The interventional studies evaluated in these reports included theatrical interventions, in-person educational presentations (e.g., workshops, symposiums, lectures, health talks), text-based interventions (e.g., posters, leaflets, factsheets, newsletters, letters), public media (e.g., radio, television, newspapers, public announcements), and online resources (e.g., videos, web-radio).

HPV education strategies primarily sought to reach girls, "potentially resulting in gender-inequitable HPV vaccination education strategies..." In most of the reports, only health professionals (29.2%, n = 14; e.g., nurses, physicians) delivered the HPV education/communication strategies. In eight of the studies (16.7%), a team of diverse providers was involved (e.g., teachers, health professionals, and community members).

Most strategies sought to improve knowledge and awareness about HPV (75%, n = 36), whereas others included outcomes related to increasing HPV vaccine acceptability. Only three strategies (6.3%) did not achieve their outcomes. "Future studies may replicate successful HPV strategies in other SSA countries to determine their impact on vaccine knowledge and uptake in those contexts."

Reflecting on the results of the review, the resarchers note that HPV educational strategies are underresearched in most LMICs, suggesting the need for more primary observational, interventional, and experimental research, as well as programme evaluations, focused on HPV educational strategies and theoretically informed. With regard to theory, given the broad range of complex individual and structural factors that impact HPV vaccination, the researchers suggest that the intersectionality theoretical framework, which helps examine how different social identities intersect to create multiple levels of privileges and marginalisation, might assist in understanding the HPV educational needs of diverse SSA populations.

In conclusion: "Once additional studies are added to the body of evidence, it will be valuable to review and synthesize diverse sources of evidence to determine what educational strategies are most useful and have the greatest impact on HPV vaccination in these settings, particularly Sub-Saharan Africa."