Barriers to the HPV Vaccination Program in the Eastern Mediterranean Region: A Narrative Review

"Lack of knowledge creates a vacuum and encourages the spread of misinformation on social networks....There is an urgent need for greater social awareness about the necessity of HPV vaccination."

National human papillomavirus (HPV) vaccination programmes (NVPs) have been implemented in at least 107 countries worldwide, yet only 2 of them (Libya and the United Arab Emirates) are in the Eastern Mediterranean Region (EMR) of the World Health Organization (WHO). This study assesses the main barriers to the integration of HPV vaccination in the NVP of the EMR's 22 countries, which includes a population of 680 million people.

The researchers performed a narrative review of papers included in Medline, Scopus, Embase, and Web of Science (last update: December 2021). The search was not subject to any limitation in terms of time or method. Thirty-one descriptive studies that dealt with the obstacles or the needs of vaccination programmes in 15 EMR countries were included in the review.

Per the literature, the most common barriers to HPV vaccination are the following:

• Lack of knowledge and awareness: Due to the absence or paucity of public education, the majority of the residents in the EMR countries are unaware of the availability of the HPV vaccine. Healthcare providers themselves do not have sufficient knowledge about the vaccine and so are unlikely to recommend it. People in the EMR who are aware of the HPV vaccine's existence reportedly have concerns about possible long- and short-term side effects.
• Economic barriers: Given the population structure (large and growing young population) in EMR countries, the large number of persons eligible for vaccination, and the number of required doses (3 doses), the provision of a sufficient budget for public vaccination is a challenging issue for many countries in the region.
• Social insecurity in conflict zones: Of the 22 member states of the EMR, 6 suffer from internal wars and insecurity. Timely delivery of the HPV vaccine in such settings is very challenging. For example, schools are one of the appropriate places for administration of the HPV vaccine. However, a large number of girls in economically poor and conflict-ridden societies do not attend school or drop out after primary school.
• Cultural norms and religion: The HPV vaccine is known to prevent sexually transmitted diseases, which raises cultural as well as religious concerns in the EMR context. Given that all EMR member states are predominantly Muslim, Islam does determine the sexual behaviour of individuals in EMR countries, abd religious activists may oppose the HPV vaccine because they believe it encourages premarital sexual activity. Cultural circumstances cause mothers to believe that their daughters are not at risk for HPV and do not need the vaccine.

Based on the findings, the paper offers a number of suggestions, such as around enhancing social awareness and mobilisation. In the EMR context, educational initiatives for women may be most successful if designed to increase awareness of their susceptibility to HPV infection and transmission. School-based meetings could serve as a useful sensitisation strategy to enhance the quantity and quality of knowledge about cervical cancer and the HPV vaccine. Culturally sensitive training programmes addressing parents' concerns about side effects of the vaccine are warranted. The researchers also recommend inclusion of HPV vaccination in the curricula of undergraduate-level medicine and paramedic training programmes.

Relatedly, in light of the fact male-dominated culture requires the spouse's consent to a woman's vaccination, men's education about HPV should be included in the agenda of the health system. Advocacy programmes would be needed for introducing the HPV vaccine, as would strong partnership and collaboration with all stakeholders. Recommendations about the vaccine by healthcare authorities and its approval by decision-makers in each country could encourage mothers to accept the vaccine.