Allison Bingham

Factors affecting utilization of cervical cancer prevention services in low-resource settings

Strategies for introducing or strengthening cervical cancer prevention programs must focus on ensuring that appropriate, cost-effective services are available and that women who most need the services will, in fact, use them. This article summarizes the experiences of research projects in Bolivia, Peru, Kenya, South Africa, and Mexico. Factors that affect participation rates in cervical cancer prevention programs are categorized in three sections. The first section describes factors that arise from prevailing sociocultural norms that influence womens views on reproductive health, well being, and notions of illness. The second section discusses factors related to the clinical requirements and the type of service delivery system in which a woman is being asked to participate. The third section discusses factors related to quality of care. Examples of strategies that programs are using to encourage womens participation in cervical cancer prevention services are provided. This paper is available too at: http://www.insp.mx/salud/index.html.

Sociocultural Issues in the Introduction of Human Papillomavirus Vaccine in Low-Resource Settings

OBJECTIVES (1) To synthesize sociocultural results from diverse populations related to vaccine decision-making, understanding of cervical cancer and its etiology, experience with previous vaccinations, human papillomavirus (HPV) vaccine concerns, and information needed to foster acceptance; (2) to contextualize findings in light of recent studies; and (3) to discuss implications for communication strategies to facilitate vaccine acceptance. DESIGN Descriptive qualitative synthesis of sociocultural studies in 4 countries using iterative theme-based analyses. SETTING Four developing countries: India, Peru, Uganda, and Vietnam. PARTICIPANTS Criterion-based sample of 252 focus-group discussions and 470 in-depth interviews with children, parents, teachers/administrators, health workers/managers, and community/religious leaders. A knowledge, attitudes, and practices survey was administered to 879 children and 875 parents in Vietnam. RESULTS We found that vaccine decision-making was primarily done by parents, with children having some role. Understanding of cervical cancer and HPV was limited; however, the gravity of cancer and some symptoms of cervical cancer were recognized. Vaccination and government-sponsored immunization programs were generally supported by respondents. Sentiments toward cervical cancer vaccines were positive, but concerns about quality of delivery, safety, adverse effects, and the effect on fertility were raised. Communities requested comprehensive awareness-raising and health education to address these concerns. CONCLUSION Sociocultural studies help elucidate the complexities of introducing a new vaccine from the perspective of children, parents, and communities. Strategies for introducing the HPV vaccine should address community concerns through effective communication, appropriate delivery, and targeted advocacy to make the program locally relevant.

Involving the community in cervical cancer prevention programs.

Underutilization of cervical cancer prevention services by women in the high‐risk age group of 30–60 years can be attributed to health service factors (such as poor availability, poor accessibility, and poor quality of care provided), to womens lack of information, and to cultural and behavioral barriers. The Alliance for Cervical Cancer Prevention (ACCP) partners have been working to identify effective ways to increase womens voluntary participation in prevention programs by testing strategies of community involvement in developing countries. The ACCP experiences include developing community partnerships to listen to and learn from the community, thereby enhancing appropriateness of services; developing culturally appropriate messages and educational materials; making access to high‐quality screening services easier; and identifying effective ways to encourage women and their partners to complete diagnosis and treatment regimens. Cervical cancer prevention programs that use these strategies are more likely to increase demand, ensure follow‐through for treatment, and ultimately reduce disease burden.

Health systems and immunization financing for human papillomavirus vaccine introduction in low-resource settings

This descriptive qualitative study synthesizes health system and immunization financing assessments performed through formative research in India, Peru, Uganda, and Vietnam using a non-probability sample of national and sub-national stakeholders; and recommends appropriate and effective strategies for HPV vaccine delivery in low-resource settings. We conclude that maximum feasibility and acceptability and lowest cost for delivering HPV vaccine can be achieved by implementing through national immunization programs; by partnering with other sectors, such as education and maternal-child health; by strengthening existing human resources and cold chain infrastructures where needed; and finally, by considering schools for reaching the target population.

An Approach to Formative Research in HPV Vaccine Introduction Planning in Low-Resource Settings

Introduction: Formative research can inform country-level HPV vaccine delivery strategies, communication messages, and advocacy plans. This paper describes our formative researchs conceptual framework; details our applied methodology; summarizes our field experience and challenges; and outlines best practices for formative research in vac- cine introduction. Methods: From 2006-2008, literature reviews, stakeholder mapping, sociocultural studies, health system assessments, and policy reviews were conducted. Data collection at individual, interpersonal, community, institutional, and policy levels in- cluded in-depth interviews, focus groups, surveys, observations, secondary data, and facility audits. Data were analyzed thematically using an iterative process. Discussion: Integrated formative research can be implemented in low-resource settings, but may require overcoming op- erational challenges. Best practices in applied formative research include a conceptual framework, multidisciplinary ap- proach, and rapid dissemination of results.

Community perceptions of malaria and vaccines in two districts of Mozambique

BackgroundMalaria is a leading cause of mortality and morbidity in Mozambique, with nearly three-quarters of the country’s malaria-related deaths occurring in children younger than five years. A malaria vaccine is not yet available, but planning is underway for a possible introduction, as soon as one becomes available. In an effort to inform the planning process, this study explored sociocultural and health communications issues among individuals at the community level who are both responsible for decisions about vaccine use and who are likely to influence decisions about vaccine use.MethodsResearchers conducted a qualitative study in two malaria-endemic districts in southern Mozambique. Using criterion-based sampling, they conducted 23 focus group discussions and 26 in-depth interviews. Implementation was guided by the engagement of community stakeholders.ResultsCommunity members recognize that malaria contributes to high death rates and affects the workforce, school attendance, and the economy. Vaccines are seen as a means to reduce the threat of childhood illnesses and to keep children and the rest of the community healthy. Perceived constraints to accessing vaccine services include long queues, staff shortages, and a lack of resources at health care facilities. Local leaders play a significant role in motivating caregivers to have their children vaccinated. Participants generally felt that a vaccine could help to prevent malaria, although some voiced concern that the focus was only on young children and not on older children, pregnant women, and the elderly. Probed on their understanding of vaccine efficacy, participants voiced various views, including the perception that while some vaccines did not fully prevent disease they still had important benefits. Overall, it would be essential for local leaders to be involved in the design of specific messages for a future malaria vaccine communications strategy, and for those messages to be translated into local languages.ConclusionsAcceptance of routine childhood vaccines bodes well for a future malaria vaccine. Vaccinating children is a well-established routine that is viewed favourably in Mozambique. A communications strategy would need to build on existing immunization efforts and use trusted sources—including current government dissemination arrangements—to deliver health information.

Assessing participation of women in a cervical cancer screening program in Peru

OBJECTIVE To assess systemic and individual factors influencing participation of women in a screening program for cervical cancer. METHODS In November 2000, a new cervical cancer screening program was introduced in the Region of San Martin, Peru. A total of 107 683 women, ages 25-49, were eligible for screening. This report covers the initial period from program inception through 31 October 2003. We used data from the program information system to identify systemic factors and individual characteristics influencing womens participation. We conducted a three-step analysis: we assessed systemic factors at the level of micronetworks or group of health centers, we estimated the odds of being a new user (never screened or not screened in the past 5 years) according to sociodemographic characteristics, and we assessed how women learned about the availability of screening services while controlling for influential factors identified in previous analyses. RESULTS During the 3-year period, 36 759 eligible women attended screening services, for a participation rate of 32.3%. While attendance varied by area and time period, the program attracted 12 208 new users. Health care micronetworks with available static screening services had higher participation. New users were more likely than regular users to have less education and to report low use of family-planning services. All other factors being equal, they were also more likely than regular users to hear about screening services from a health care provider. CONCLUSION In this setting, the presence of and contact with health services played a role in increasing the participation in screening of women not previously screened or not screened in the past 5 years.

Policy Development for Human Papillomavirus Vaccine Introduction in Low- Resource Settings

The objectives of this analysis are: (1) to describe the policy environment related to human papillomavirus (HPV) vaccine introduction; (2) to identify the policy processes and key stakeholders in HPV vaccine introduction; (3) to summarize specific characteristics about HPV vaccines and their introduction that may be barriers to introduction; and (4) to recommend advocacy strategies to achieve a positive environment for cervical cancer prevention. This descriptive qualitative study of HPV vaccine policy development used an iterative, inductive, theme-based approach to data analysis. The study was conducted in four developing countries—India, Peru, Uganda, and Vietnam. Study participants were comprised of a total of 237 national policymakers, legislators, officials, and senior managers from ministries of health, finance, and planning; leaders of medical and health professional associations; cancer institutes; heads of nongovernmental organizations; and womens health advocates. While differences existed among low-income countries in specific cervical cancer, womens health, adolescent health, or immunization policy environments, we found the policymaking process itself, specific concerns related to HPV vaccines, and the information needs of policymakers for HPV vaccine introduction to be strikingly similar. Data on burden of cervi- cal cancer, HPV vaccine safety and efficacy, and cost-effectiveness and vaccine affordability were top issues reported by policymakers. Advocacy strategies need to address these issues in order for HPV vaccine policy formulation and approval to be successful.

Perceptions of malaria and vaccines in Kenya

Malaria is a leading cause of morbidity and mortality in Kenya. To confront malaria, the Government of Kenya has been implementing and coordinating three approaches - vector control by distributing insecticide-treated bed nets and indoor residual spraying, case management, and the management of malaria during pregnancy. Immunization is recognized as one of the most cost-effective public health interventions. Efforts are underway to develop a malaria vaccine. The most advanced (RTS,S), is currently going through phase 3 trials. Although recent studies show the overwhelming support in the community for the introduction of a malaria vaccine, two issues - culture and the delivery of child immunization services - need to be considered. Alongside the modern methods of malaria control described above, traditional methods coexist and act as barriers to attainment of universal immunization. The gender dimension of the immunization programme (where women are the main child caretakers) will also need to be addressed. There is an age dimension to child immunization programmes. Two age cohorts of parents, caregivers, or family members deserve particular attention. These are the youth who are about to initiate childbearing, and the elderly (particularly mother-in-laws who often play a role in child-rearing). Mothers who are less privileged and socially disadvantaged need particular attention when it comes to child immunization. Access to immunization services is often characterized in some Kenyan rural communities in terms of living near the main road, or in the remote inaccessible areas. Should a malaria vaccine become available in the future, a strategy to integrate it into the immunization programme in Kenya should take into account at least two issues. First, it must address the fact that alongside the formal approach in malaria control, there exist the informal traditional practices among communities. Secondly, it must address particular issues in the delivery of immunization services.

Factors likely to affect community acceptance of a malaria vaccine in two districts of Ghana: a qualitative study.

Malaria is a leading cause of morbidity and mortality among children in Ghana. As part of the effort to inform local and national decision-making in preparation for possible malaria vaccine introduction, this qualitative study explored community-level factors that could affect vaccine acceptance in Ghana and provides recommendations for a health communications strategy. The study was conducted in two purposively selected districts: the Ashanti and Upper East Regions. A total of 25 focus group discussions, 107 in-depth interviews, and 21 semi-structured observations at Child Welfare Clinics were conducted. Malaria was acknowledged to be one of the most common health problems among children. While mosquitoes were linked to the cause and bed nets were considered to be the main preventive method, participants acknowledged that no single measure prevented malaria. The communities highly valued vaccines and cited vaccination as the main motivation for taking children to Child Welfare Clinics. Nevertheless, knowledge of specific vaccines and what they do was limited. While communities accepted the idea of minor vaccine side effects, other side effects perceived to be more serious could deter families from taking children for vaccination, especially during vaccination campaigns. Attendance at Child Welfare Clinics after age nine months was limited. Observations at clinics revealed that while two different opportunities for counseling were offered, little attention was given to addressing mothers’ specific concerns and to answering questions related to child immunization. Positive community attitudes toward vaccines and the understanding that malaria prevention requires a comprehensive approach would support the introduction of a malaria vaccine. These attitudes are bolstered by a well-established child welfare program and the availability in Ghana of active, flexible structures for conveying health information to communities. At the same time, it would be important to improve the quality of Child Welfare Clinic services, particularly in relation to communication around vaccination.