THE IMPACT OF IMPROVED HEALTH LITERACY AND GREATER ACCESS TO VACCINES ON HPV

PREVENTION IN LOW- AND MIDDLE-INCOME COUNTRIES 1

The Impact of Improved Health Literacy and Greater Access to Vaccines on HPV
Prevention in Low- and Middle-Income Countries:

Sharangi Vasavan
Student Number: 1002646915
Department of Health & Society, University of Toronto
HLTB41H3: Introduction to the Social Determinants of Health
Tutorial 4
Dr. Fazli
November 15th, 2021
THE IMPACT OF SOCIOECONOMIC FACTORS ON HPV PREVENTION 2

Introduction:

Human papillomavirus (HPV) infection is recognized as one of the primary causes of

infection-related cancer in both men and women around the world. HPV is responsible for
almost all cervical cancer cases (80%), and a small number of cases for anogenital cancers
(vulvar, vaginal, penile, and anal) and for oropharyngeal cancers (base of tongue, tonsil cancer,
head, neck, and throat). Despite radical changes and advancements in HPV cancer screening,
diagnosis and vaccine development, HPV infection still has a significant disease burden, with
two-thirds of cases in developing countries affecting mostly young individuals (less than 25
years for women), and a clear decline with age. However, in some regions such as Western
Africa and Central and South America, a second peak of HPV incidence is seen in older women.
Hispanic, African American, and Vietnamese women also disproportionally experience higher
rates of cervical cancer incidence and mortality than do non-Hispanic Caucasians (Fernandez,
Allen, Mistry, & Kahn, 2010). Statistics from a study in 2017 show that 4.5% of all cancers
worldwide (630,000 new cancer cases per year) are attributable to HPV with 8.6% in women and
0.8% in men. HPV contributed to 29.5% of infection-related cancers worldwide in 2012 and
caused more than half of all infection-attributable cancers in women (570,000 cases). Cervical
cancer is the fourth leading cause of cancer deaths worldwide (second in women aged 15-44
years), with more than 84% of the cases (445,000 annually) being diagnosed in less developed
countries. In comparison, in more developed regions, cervical cancer contributes to less than 1%
of all cases in women (83,000 annually). Asia has seen the most cervical cancer cases (285,000
cases; 54.0%) and deaths (144,000 deaths; 54.7%), followed by Africa (99,000 new cases and
60,000 deaths) and the Americas (83,000 new cases and 36,000 deaths). These differences in
incidence and mortality rates can be explained by the quality and awareness of HPV diagnosis,
vaccine prevention and treatment along with changes in lifestyle factors such as sexual behaviour
and exposure to HPV. The overall burden of disability-adjusted life years (DALYs) lost due to
cervical cancer was 6.9 million years in 2013, with 5.8 million years occurring in less developed
regions. In 2013, cervical cancer was among the top three causes for DALYs in women, after
breast and lung cancer. Between 1990 and 2013, a downward trend in age-standardized DALY
rates was observed, with a global 32% decrease (34% and 36% in more and less developed
regions, respectively). To reduce the global burden of HPV-related cancer, primarily in low-
income countries (LMC), greater investments in health literacy and education of eligible children
THE IMPACT OF SOCIOECONOMIC FACTORS ON HPV PREVENTION 3

and their parents must be made so that they are aware of the true protective effect of the vaccine.
Once that is achieved, improving affordability and access to HPV prevention services, primarily
vaccination, is crucial to ensure that low-income countries are not disadvantaged (Serrano,
Brotons, Bosch, & Bruni, 2018).

Evidence on SDOH # 1:

Research has shown that limited understanding about the association between HPV and
cancer is common among the general population and among individuals diagnosed with HPV-
associated cancers. Knowing one’s HPV status is crucial as it may influence prognosis, treatment
and future sexual health decisions for the affected individual, their families, and current sexual
partners. Using a health literacy framework (Sørensen et al., 2012), a study attempted to identify
the gaps in patients’ ability to access, understand, appraise, and apply HPV information.
According to the framework, through these four domains, an individual is to acquire and use
relevant information to make informed health decisions. Patients from this study recalled a lack
of healthcare providers educating them on HPV (access), confusion about the cause of their
HPV-related cancer (understand), difficulty making a connection between HPV, their cancers
and lifestyle factors such as their number of sexual partners (appraise) and limited discussion
regarding HPV preventative practises such as getting the vaccine or greater use of contraception.
In another study by Johnson et al. (2014), results showed that awareness of cervical cancer, HPV
infection and vaccine uptake were positively correlated with having any formal education, usage
of contraception, and having a history of abortion or reproductive issues. This suggested that
women who were accessing health care services, especially for gynecological problems, had
greater health literacy pertaining to HPV due to the information being transferred from medical
provider to patient during clinical visits. A major issue with access on the meso level is that
medical providers often struggle to relay HPV information and discuss sexual behaviours with
patients due to its stigmatizing effect. Without proper health literacy, patients were found to
spend less time engaging in health information-seeking and health promoting behaviors (Best et
al., 2018). For younger individuals, parents tend to oversee medical decision-making on their
behalf. Ensuring proper HPV education and vaccine approval among immigrant parents of
adolescents can also be found challenging as some parents are unable to understand educational
information due to language barriers. Another issue is that HPV has become feminized due to the
THE IMPACT OF SOCIOECONOMIC FACTORS ON HPV PREVENTION 4

vaccine initial development and marketing focused on females to prevent cervical cancer. As a
result, a cultural narrative that HPV was a ‘women’s problem’ and gender inequalities formed
for the treatment of HPV-related cancer. Examinations of the effect of HPV on anal and oral
cancer in men occurred a decade after similar studies among women, which resulted in a lag in
epidemiological evidence that could be used for vaccine recommendations for males. From a
public health standpoint, feminization of the HPV vaccine was initially seen as cost-effective
since a major of HPV-related cancer cases were cervical. Therefore, focusing on vaccinating
more women was thought to best facilitate a state of herd immunity. However, we are no where
near that threshold and this logic is flawed as it doesn’t account for anal cancer cases seen in men
who have sex with men. Another consequence of the delay in male HPV vaccine approval was
that females showed greater awareness and knowledge of HPV compared to males, which is
likely attributable to media and health campaigns only targeting females for a long period of
time. As a result, females and parents of females were more likely to receive HPV information
and vaccine recommendations by their healthcare provider compared to males (Daley et al.,
2017). Furthermore, studies showed that parents expressed cultural concern that HPV
vaccination would send a message to their children that they approved of early sexual
promiscuity or premarital sex, which contributed to greater vaccine hesitation and an
unwillingness to engage in HPV-related education (Fernandez, Allen, Mistry, & Kahn, 2010).

Evidence on SDOH # 2:

Another important factor that contributes to lower HPV incidence rates is the
affordability and access of vaccines in LIC and middle-income countries (MIC). Currently, there
is a 15% global coverage of the HPV vaccination, with only 22 of the 78 LIC and lower-middle
income countries (LMIC) having introduced the vaccine by 2020. This is well behind the 50 of
57 high-income countries (HIC) and 35 of 59 upper-middle income countries that have
introduced the vaccine. As a result, less than 25% of girls living in LIC and LMIC have had
access to the vaccine. This inequity of access has been driven by high cost of vaccines, cost of
delivery and a shortage of vaccine supply. Since 2011, Gavi, the Vaccine alliance and UNICEF
made HPV vaccines accessible to all LIC and some LMIC at subsidized prices for as little as
$4.50 per dose. In addition, the cost of HPV vaccines for MICs is about three times the cost of
the price for Gavi-eligible countries. However, since the manufacturing cost of producing an
THE IMPACT OF SOCIOECONOMIC FACTORS ON HPV PREVENTION 5

HPV vaccine is considerably lower than the GAVI purchase price, there could be room to
negotiate the price further for countries in need. Costs of vaccine delivery must also be
accounted for when implementing vaccine programs, which include a proportion attributable to
start-up costs like training and generating demand through social mobilization. The delivery of
HPV vaccines through a school-based program has been proven to be the most effective
approach to date. However, a financial barrier exists as the cost of delivering vaccines through
school-based programs is higher than the cost for health facility-based strategies. Reaching a
high coverage of the second dose has also been a challenge for some countries due to poor
mechanisms for tracking girls for follow-up after their first dose. Also, Gavi’s reduced pricing
along with an increased vaccination of older women and boys has contributed to an increased
demand from LIC/LMIC and, as of 2017, a global vaccine shortage. This disruption is projected
to delay introduction of the vaccine in other LICs/LMICs until 2024, by when supply is expected
to improve from both existing and new manufacturers. Introduction of novel vaccines for HPV
or a reduction of dosing requirements for HPV protection can also help improve the supply and
drive a reduction in costs by increasing competition among manufacturers. Improvements in
global health investments can also help increase supply as inequalities exist in healthcare
spending. Currently, 32.1% of development assistance for health has been allocated for maternal,
reproductive, newborn, and infant health services, whereas only 2% of Development Assistance
has been allocated to health services for cancers along with other non-communicable diseases,
which constitute over 60% of the global disease burden (Kumar et al., 2020). Access to resources
such as technical assistance from experienced partners and country-to-country learning can help
foster sustainable, effective national HPV vaccine delivery. As seen in Rwanda, political
influence is crucial for the implementing of HPV vaccines as support from national policy
makers can help secure more funding from government agencies. Partnership with Civil Society
Organizations, other professional, cultural, and religious associations, such as cancer societies
and youth groups, have been crucial in creating demand and gaining political support from
Members of Parliament (MPs) and policymakers. Furthermore, strategic use of existing
processes used by other national immunization programs to efficiently deliver and optimize costs
for the HPV vaccine would make it easier for programs to acquire funding from ministries of
health, ministries of finance, and international donors. This includes introducing HPV
vaccination with other important adolescent vaccinations in existing health system infrastructure
THE IMPACT OF SOCIOECONOMIC FACTORS ON HPV PREVENTION 6

such as school-based delivery programs, training sessions for healthcare providers for other
infectious diseases, community outreach and education programs. Planning is also crucial for
successful vaccine delivery, which consists of coordinating with the education sector for school-
based vaccinations; sensitizing national stakeholders and parents of eligible children; ensuring
children have insurance coverage; tracking registration of eligible children and completion of
second doses, especially those who are not in school (LaMontagne et al., 2017).

Policy Solutions to Address the problem:

One potential intervention that can improve vaccine uptake and reduce the prevalence of
HPV-related cancers is that a benchmark can be implemented that requires healthcare providers
or schools to achieve a pre-determined level of vaccination in their eligible patients. Health
insurance plans that implement these policies can reward providers who reach the targeted level
and enforce consequences like a tax on those who fail to achieve the benchmark. This provides
an incentive for vaccine providers to ensure that eligible children and/or their parents have a
sufficient understanding and awareness of HPV, HPV-related cancers, and the vaccine.
Additional training can be provided by medical educators to ensure that providers are equipped
with the knowledge and communication skills needed to promote better health decision-making
and make better recommendations to parents and children. For patients, better HPV education
can also be achieved through the administration of interactive, educational modules or videos
that can be mandated at schools. For those who are home-schooled and don’t have access to
technology, engaging HPV vaccination educational materials and promotion brochures can be
mailed to homes or distributed by healthcare providers to eligible children and their parents.
These videos and materials must be approved by professional healthcare providers and/or
medical educators prior to distribution as provider recommendation has been known as an
interpersonal factor associated with greater vaccine uptake (Head, Biederman, Sturm & Zimet,
2018). This strategy has also been deemed effective based on the results from a study in which
60% of parents who watched a brief HPV and HPV vaccine educational video and then answered
questions which encouraged them to develop reasons for vaccinating were pro-HPV vaccination
after participating in the study (Baldwin et al., 2017). Another intervention that can be used
involves greater implementation of school-based vaccine programs and the use of automated
reminders to increase on-time completion of the two or three dose HPV vaccine series.
THE IMPACT OF SOCIOECONOMIC FACTORS ON HPV PREVENTION 7

Participants (females and males) will be eligible for such programs once they reach age 9 up
until they turn 13 and can choose their preferred method of reminders for their subsequent
dose(s) whether it be text, phone, e-mail, private Facebook message, or standard mail. School-
based vaccine programs have shown efficacy in various countries in the past. For example, in a
study by Paul and Fabio (2014) that looked at experiences in 17 developing and developed
countries with this program, vaccine uptake and coverage (competition of all doses) rates in girls
between the ages of 9-13 were reported as low as 65% in Manchester’s program to as high as
96% in the program in Vietnam. These rates were higher in comparison to health-facility based
vaccine programs due to ease of access to the target population. However, mixed programs,
which used both schools and health-facilities (if a vaccine dose is missed at school) as sites for
vaccine administration was found to be as effective as school-based programs. The use of
automatic reminders and better tracing mechanisms to improve timely completion of 2 nd and 3rd
HPV vaccine dose(s) is also projected to be effective as it has been linked to 1.5 times increase
in coverage (Vann & Szilagyi, 2009). Based on results from a study by Harvey, Reissland &
Mason (2015)., reminding parents that their children were due or overdue for the HPV
immunizations contributed to a 10.6% increase in vaccine uptake when postal reminders were
used, a 4% increase when telephone reminders were used and up to 18.9% increase when a
combined telephone and postal approach was used. In addition to simple reminders, text
messages, emails and standard mail can also be sent out routinely to parents with unvaccinated
kids containing general information on HPV and cancer along with educational messages on why
they should vaccinate their children.

Conclusion:

Global analysis of HPV vaccination coverage data has suggested that only 1% of young
women between the ages of 10–20 years in LICs and LMIC had been fully vaccinated by the end
of 2014. Despite advancements, the reach of HPV vaccines in countries with the highest rates of
HPV-related cancer is still lagging. Given these global disparities, understanding the system-level
barriers to vaccination completion are crucial to increase access and improve uptake. Studies have shown that
poor health literacy regarding HPV among parents of adolescents and older women has contributed to poor
health decision-making and lower vaccine uptake. Factors such as language barriers, stigma pertaining to
HPV’s association with sexual promiscuity and premarital sex, access to gynecological health services and the
feminization of HPV have all contributed to inequalities in health literacy among different populations. One
THE IMPACT OF SOCIOECONOMIC FACTORS ON HPV PREVENTION 8

potential policy intervention to improve health literacy rates is the use of a benchmark requirement for vaccine
providers to achieve a pre-determined level of vaccination in their eligible patients where and those who fail to
reach the benchmark will incur a tax. In addition to education, studies have shown that poor vaccine uptake
can be attributed to issues with affordability and access of vaccines in LIC and MIC. Factors such as
high vaccine costs, the delivery approach used to administer vaccines, quality of systems used
for tracking and recording completion of both doses, supply interruptions, inequalities in
government healthcare investments and spending, political support from policymakers and MPs
and proper planning of vaccination programs all play a role in the administration of vaccines and
must be addressed. Another intervention that can improve access and reach of HPV vaccines is
the use of school-based vaccine programs and automated reminders for completion of subsequent
doses. Doing so can hopefully help achieve WHO’s global target of vaccinating 90% of all
adolescent girls by 2030 and eliminate cervical cancer globally by 2100 (Kumar et al., 2020).
THE IMPACT OF SOCIOECONOMIC FACTORS ON HPV PREVENTION 9

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