Advocacy, communication, and training

Advocating and training for cervical cancer prevention

Accurate information is essential to improving understanding of both HPV and cervical cancer among health care workers, educators, policymakers, parents, and patients. Many do not know the cause and burden of cervical cancer and may not be able to understand the value of HPV vaccines or cervical screening for improving the current situation. Without such understanding and strong advocacy, individuals are unlikely to support these interventions.^5,53,71

To improve knowledge, it is advisable first to decide how best to “frame” the information by considering sociocultural realities. Effective framing can help to avoid social resistance from, for example, groups that fear that HPV vaccines will promote promiscuity (even though studies have shown that sex education has the opposite effect).^5,79,80 Community readiness and acceptance will help to ensure access to vaccination and screening programs, so community leaders should be involved in the design and implementation from the beginning.

HPV vaccine is well accepted in many communities

Recent experience in India, Peru, Uganda, and Vietnam provides guidance in ways to frame HPV vaccination in developing countries. Based on the results of extensive audience and systems research, all four country programs made the strategic decision to emphasize the protective effect of the vaccine against cancer rather than emphasizing the mode of transmission (sexual activity) or the disease agent (HPV) when educating community members. Posters, local radio spots, brochures, and other media for the general public promote “cervical cancer vaccine.” (But when communicating with more educated health professionals, materials use the phrase “HPV vaccine” since these individuals are more likely to understand that term.) This strategic choice seems to have paid off, as community acceptance rates of the vaccine are much higher than expected for a new vaccine that had not been part of the routine government immunization program. Project staff believe that once parents understand the basics of cervical cancer, they reason along these lines: (1) in general, communities have faith in immunization; (2) they are concerned about cancer, even when they are not very knowledgeable about it; and (3) they say that if a vaccine against cervical cancer is safe, effective, and affordable, they want their daughters vaccinated.³⁸

The country teams also have been pleased to find that potential sociocultural concerns have not arisen. Possible concerns included the fear that parents would distrust a vaccine offered only to girls or that they would worry that giving their daughters a vaccine against a sexually transmitted infection could disinhibit the girls from early sexual experimentation. There also was concern that conservative religious leaders might take a stand against HPV vaccination for the same reasons. But none of these scenarios has developed significantly in the four countries. This is likely due to the extensive educational work done in the communities prior to vaccine introduction. In villages or schools where pre-introduction communication was weaker, coverage tended to be low until additional educational outreach was implemented.

One unanticipated challenge arose during field work—confusion between HPV and HIV. As mentioned in the HPV and cervical cancer page, sometimes people assume that because both HIV and HPV are sexually transmitted, prevention strategies would be similar. However, while reducing numbers of sexual partners and consistent use of condoms can dramatically reduce HIV infection, those strategies are not as effective against HPV. Explaining this difference has been added as a key message in the PATH programs. Further, the use of the term “cervical cancer vaccine” can lessen confusion between the abbreviations HPV, HIV, and HBV (hepatitis B virus).

Educating health care workers

Because clinicians are often the primary source of information for both parents and adolescents, educating clinicians helps parents to understand the benefits of any vaccine.^5,52 Health care workers in many developing countries might not have a clear understanding of HPV infection and its relationship to cervical cancer development and prevention. This situation is exacerbated by the “silent nature” of cervical cancer—the fact that symptoms are not present until the cancer is at an advanced stage. Health workers need to be educated about how to help patients understand the enormous advantages offered by both screening and vaccination.^52,81,82

Photo: PATH/Amynah Janmohamed