ReviewHPV vaccine acceptability in Africa: A systematic review
Introduction
The quadrivalent human papillomavirus (HPV) vaccine is manufactured by Merck & Co. and has been available commercially since 2006. The vaccine protects against strains of HPV that cause approximately 70% of cervical cancer cases and 90% of anogential wart cases worldwide. The cost is high (approximately $400 US for a three-series dose) and until recently this presented a significant barrier to implementation within low-resource countries. The Global Alliance for Vaccine Initiatives (GAVI) recently negotiated a $4.50/dose fee for GAVI-supported countries. At the same time, GAVI announced support for eight projects in African countries that will begin over 2013–2014 (GAVI, 2013). This is positive as in the past there have been decades of delay between new vaccine production and implementation in developing countries (Kane et al., 2006).
African countries carry the largest burden of cervical cancer worldwide. Globally, the prevalence of HPV infection is estimated at 11–12%; however in sub-Saharan Africa (SSA) the estimate is substantially higher at 24% (Forman et al., 2012). In 2008, world estimates of new cervical cancer cases were 530,000, and 75,000 of these were from SSA countries, representing almost 15% of the world's burden (Forman et al., 2012). This burden is largely due to the lack of organized, preventative services, such as cytological screening (i.e. Pap smears), and the prevalence of risk factors for the disease (Bosch and de Sanjosé, 2003, Sankaranarayanan and Ferlay, 2006). Coinfection with HIV also increases the risk of HPV infection and progression by substantially reducing immunity (Palefsky et al., 2006). Promisingly, widespread vaccination with the HPV vaccine is expected to substantially reduce the burden of cervical cancer, especially when combined with other preventative measures (Garnett et al., 2006).
Health behaviors are conceptually complex and a number of frameworks have been used for their explanation. One that has been used to understand vaccination and cervical cancer screening behaviors in the past is the Health Belief Model (HBM) (Allen et al., 2010, Brewer and Fazekas, 2007, Johnson et al., 2008, Prematunge et al., 2012). As an expectancy model, the HBM predicts that an individual's health behavior will depend on the value placed on achieving a goal and the belief that a certain behavior will achieve that goal (Poss, 2001). The model includes aspects of perceived likelihood (individual susceptibility), perceived severity, and perceived effectiveness and benefits. There are also cues to action (external or internal stimuli) and perceived barriers to action. In this review, in addition to these five constructs, HPV vaccine-related awareness and knowledge and other modifying factors previously found to predict acceptability are included.
The purpose of this paper is to present a systematic review of peer-reviewed literature on the factors associated with HPV vaccine acceptability among adults with and without children from African countries. Acceptability in this context refers to a reported/predicted willingness and intention to receive a vaccination, and not actual uptake. A systematic review similar to this topic has been published recently (Perlman et al., 2014); however the current review is unique in its focus on adults, the quantification of results and use of the HBM framework which allows comparability to a previous US review (Brewer and Fazekas, 2007).
Section snippets
Search strategy
A health sciences librarian with experience conducting systematic reviews assisted with the search of five electronic databases: EMBASE, PsychINFO, CINAHL, Global Health and Ovid MEDLINE (August 2013). All literature relating to HPV vaccination in African countries was sought and the search consisted of database-specific vocabulary and use of Boolean operators for: human papillomavirus vaccin* and Africa. No restriction was placed on date or language. Reference sections of included articles
Results
As shown in Fig. 1, 229 unique articles were identified after database searches, 29 were given full-text review with 14 meeting inclusion criteria. One article was identified by hand-searching (Ports et al., 2013). The final number of articles included in this review is 15 representing 14 unique studies (Table 1). These studies span ten countries from SSA: Botswana (1), South Africa (2), Nigeria (2), Kenya (3), Ghana (1), Uganda (1), Mali (1), Zambia (1), Tanzania (1) and Malawi (1). At the
Discussion
This systematic review found high acceptance of the HPV vaccine among young adults, adults, and parents in SSA countries, despite low awareness of HPV and the HPV vaccine. This review was structured using the Health Belief Model (HBM) and demonstrates the utility of the HBM for integrating qualitative and quantitative research findings for understanding the factors influencing vaccine acceptance.
The included studies were moderately-sized, quantitative cross-sectional studies and qualitative
Conclusion
Implementation of the HPV vaccine in African countries is an important step towards reducing the high burden of cervical cancer in this region. Recent announcements from the GAVI of HPV vaccine demonstration projects beginning in SSA offer an encouraging step toward this goal. Based on this review, the acceptability and uptake of the HPV vaccine among these countries are expected to be high. However, broad knowledge gaps have been highlighted and should be addressed. Efforts to educate about
Conflict of interest
The authors declare no conflict of interest.
Acknowledgments
We would like to thank Amanda Ross-White for her assistance and expertise with electronic literature searches. As a graduate student during this work, we would like to acknowledge that MSC was supported by the Ontario Graduate Scholarship.
References (40)
- et al.
A systematic review of measures used in studies of human papillomavirus (HPV) vaccine acceptability
Vaccine
(2010) - et al.
HPV vaccine acceptability among Kenyan women
Vaccine
(2010) - et al.
Predictors of HPV vaccine acceptability: a theory-informed, systematic review
Prev. Med.
(2007) - et al.
HPV vaccine acceptability in Ghana, West Africa
Vaccine
(2011) - et al.
Global burden of human papillomavirus and related diseases
Vaccine
(2012) - et al.
Examining attitudes and knowledge about HPV and cervical cancer risk among female clinic attendees in Johannesburg, South Africa
Vaccine
(2010) - et al.
A qualitative analysis of South African women's knowledge, attitudes, and beliefs about HPV and cervical cancer prevention, vaccine awareness and acceptance, and maternal–child communication about sexual health
Vaccine
(2011) - et al.
Chapter 21: Modelling the impact of HPV vaccines on cervical cancer and screening programmes
Vaccine
(2006) - et al.
Preparing for HPV vaccination in South Africa: key challenges and opinions
Vaccine
(2009) - et al.
Chapter 15: HPV vaccine use in the developing world
Vaccine
(2006)
Human papillomavirus (HPV) infection and vaccines: knowledge, attitude and perception among female students at the University of Lagos, Lagos, Nigeria
J. Epidemiol. Glob. Health
Chapter 16: HPV vaccines in immunocompromised women and men
Vaccine
Factors influencing pandemic influenza vaccination of healthcare workers—a systematic review
Vaccine
A qualitative study of HPV vaccine acceptability among health workers, teachers, parents, female pupils, and religious leaders in northwest Tanzania
Vaccine
Determinants for HPV vaccine uptake in the Netherlands: a multilevel study
Vaccine
Predictors of HPV vaccine uptake among women aged 19–26: importance of a physician's recommendation
Vaccine
Worldwide burden of gynaecological cancer: the size of the problem
Best Pract. Res. Clin. Obstet. Gynaecol.
Awareness, acceptability and uptake of human papilloma virus vaccine among Cameroonian school-attending female adolescents
J. Community Health
Achieving high coverage in Rwanda's national human papillomavirus vaccination programme
Bull. World Health Organ.
Chapter 1: Human papillomavirus and cervical cancer—burden and assessment of causality
JNCI Monogr.
Cited by (60)
Cervical cancer in Morocco: A systematic review
2022, Revue d'Epidemiologie et de Sante PubliqueUsing branded behaviour change communication to create demand for the HPV vaccine among girls in Malawi: An evaluation of Girl Effect's Zathu mini magazine
2022, VaccineCitation Excerpt :Girl Effect conducted extensive formative and desk research, and the key barriers identified in the formative research aligned with the existing literature; low knowledge about HPV, poor understanding of the link between the virus and cervical cancer, low perceived risk of transmission, and also fear of side-effects such as infertility or the pain of the injection [1,3,12]. There are also the common beliefs that one need not address the issue of cervical cancer (either by screening or vaccination) until symptoms present themselves, that the vaccine will encourage younger girls to become sexually active [6], and a fear that the vaccine will be of a low quality [2]. It is suggested by Perlman et al [11] that there is an urgent need for more education to inform the public about HPV, the HPV vaccine and cervical cancer, and that this should be targeted at adolescents, parents and health care professionals.
A pilot study of a video-based educational intervention and knowledge of cervical cancer among senior high school students in Ghana: A before-after study
2020, Journal of Cancer PolicyCitation Excerpt :It has achieved high coverage worldwide including sub-Saharan African countries. However, the low awareness and knowledge of HPV vaccination may negatively impact the HPV vaccination programs in SSA [15,16]. Thus there is the need to investigate appropriate programs to improve uptake.