HPV Vaccine Acceptance in West Africa: A Systematic Literature Review

"With more understanding of the perspectives of the public, providers and communities, HPV vaccine strategies will be more likely to reach and protect women and girls from HPV infection and cervical cancer."

In various countries around the world, hesitancy around the human papillomavirus (HPV) vaccine has led to low HPV vaccination acceptance, with concerns often centring around safety and women's fertility, the latter perhaps due to the age at which the vaccine is typically administered (adolescence), its link to sexual health, and past coercive "health" interventions imposed by colonial administrations. The aim of this systematic literature review is to identify and analyse factors contributing to the acceptance (or lack thereof) of HPV vaccination in West African countries, identifying the spectrum of perceptions, concerns, trust, and access issues relating to the vaccine.

Thirty-five articles were included in the review. Most studies were conducted in Nigeria and, despite the search criteria including all languages, all articles found were in English. Most articles were published in 2017 and 2018, which could be due to the increased number of HPV vaccine pilot projects being introduced at this time. (As of 2021, only just over half of the West African countries (Benin, Burkina Faso, Ghana, Liberia, Mali, Mauritania, Niger, Nigeria, Senegal, Sierra Leone, and Togo) have introduced a pilot HPV vaccination programme. Sierra Leone has announced the introduction of the vaccine (start date to be determined), but Cote d'Ivoire, Liberia, Senegal, and The Gambia are the only West African countries with a national HPV immunisation programme.)

The main concerns cited in the included articles were related to inadequate HPV vaccine information, the cost of the vaccine, and safety concerns. However, most studies did not offer the opportunity for participants to provide more details about these concerns. Looking at the available data in the context of earlier research, the author notes that, in Cameroon in 1990, a rumour that public health workers were administering the tetanus vaccine to sterilise girls and women spread throughout the country, leading some schoolgirls to leap from windows to escape the vaccination teams. Controversies like these could also be linked to the fact that vaccination programmes are often organised or supported by former colonialist nations, and so it is logical that they could be cause for suspicion. Similar sentiments could explain participants' concerns about whom the HPV vaccine will be tested on in one of the included studies in Ghana; the authors observed during post-survey conversation that some participants had a suspicion of foreign-sponsored programme.

Participants in seven studies were concerned that the HPV vaccine could lead to promiscuity; one included study also found that cervical cancer itself was generally believed to be caused by female promiscuity. According to the author, the dimension of blaming women for sexually transmitted infections (STIs) and other morbidities caused by sexual interaction warrants further research and discussion.

Six of the studies examined who made vaccine decisions, and most (all three in Mali and one in Nigeria) found that men were the primary decision-makers. In one study, half of adult females said they would have to ask their husband's permission before deciding to vaccinate their child. However, a Nigerian study found that most female students would seek approval for vaccination from their healthcare worker (HCW) and mother. In addition, most respondents in a study in Ghana believed the decision to vaccinate their daughter(s) should be made by both parents or in conjunction with the daughter(s), as opposed to the government. One study also found that the adolescents in Nigeria accepted the idea of HPV vaccination but that some adults (e.g., traditional healers and religious leaders) did not, and some of the latter were not willing to allow their worshippers to accept it.

Reflecting on all the findings, the author points out that, despite the fact that over half of West African countries have introduced an HPV vaccine pilot project, there is a scarcity of literature on HPV vaccine acceptance in the region. For instance, there are wide gaps in knowledge regarding the attitudes of West African HCWs, which is significant considering the impact they have on vaccination decisions. The author encourages more in-depth analysis on the concerns and misconceptions cited by HCWs about vaccination.

In general, it should be noted that concerns about the HPV vaccine are complex, context specific, and can differ from concerns affecting uptake of routine childhood vaccinations. Understanding how cultural and gender dynamics in different settings can influence people's vaccination decisions can be pursued through in-depth local ethnographies that take the views of all community members and influencers into account.

In conclusion: "'quick-fix' interventions which aim to increase vaccination uptake, such as health communication messages..., without understanding and addressing the root cause of vaccine hesitancy in specific contexts, are likely to have little effect on people's vaccination decisions or on providers' own confidence in communicating about vaccines."