Human Papillomavirus Vaccination Practices and Perceptions among Ghanaian Healthcare Providers: A Qualitative Study Based on Multi-Theory Model

"...health workers will be armed with the right information to educate the public, dispel misconceptions and promote the uptake of the vaccine. Ultimately, this will be a giant step forward in Ghana's attempt at cervical cancer prevention and control."

The human papillomavirus (HPV) vaccine was first introduced in Ghana in 2013; as in many low- and middle-income countries (LMICs), the vaccination rates remain very low there. Studies in other countries have found that healthcare providers (HCPs), including physicians, nurses, and allied health workers, play a central role in HPV vaccine uptake. This study uses Multi-Theory Model (MTM) constructs to examine Ghanaian HCPs' attitudes towards HPV vaccination and their vaccination recommendation practices.

The MTM framework of behaviour change has two main components: (i) initiation of the behaviour change (participatory dialogue (individuals weigh advantages versus disadvantages), behavioural confidence, and changes in the physical environment) and, (ii) continuation or sustenance of behaviour (emotional transformation, practice for change, and changes in the social environment).

In May 2020, the researchers recruited 29 HCPs (15 men and 14 women between the ages of 29 and 42 years) from Ghana Health Services (GHS) and the Komfo Anokye Teaching Hospital, the second-largest government hospital in Kumasi, in the Ashanti Region of Ghana. They conducted three 60-minute focus group discussions (FGDs); 16 semi-structured open-ended questions based on MTM constructs were used to guide the FGDs. The exchanges explored HCPs' general knowledge about HPV, vaccination recommendation behaviour, physical environment, and socio-cultural factors associated with HPV vaccination. The interview themes within the MTM constructs and participants' direct quotes are presented in Table 2 of the paper.

In short, the analyses showed:

• The HCPs did not know about the health burden of HPV cases in Ghana because they reported there is no epidemiological data indicating the prevalence, incidence, morbidity, and mortality of HPV-related diseases.
• HCPs' responses revealed varied understanding about who should be vaccinated - e.g., regarding age eligibility, gender, and infection status.
• HCPs in the family care centre at the hospital reported they offer HPV vaccination education for an adolescent only when they know that an adolescent is sexually active. This is in contrast to practices in many other countries.
• Perceived barriers to HPV vaccination include: (a) low urgency for vaccination education due to competing priorities such as malaria and HIV/AIDS; (b) lack of data on HPV vaccination; (c) lack of awareness about vaccine safety and efficacy; (c) lack of HPV vaccine accessibility, and (d) stigma, misconceptions, and religious objections.

On the HCPs' sources of confidence for counseling or educating teenagers and parents about the vaccination, 3 themes emerged:

1. Predisposing factors: HCPs mentioned that knowledge of the source of the vaccine, efficacy of the vaccine, safety profile of the vaccine, and public awareness of the seriousness of HPV could improve their confidence level for providing it to the client.
2. Enabling factors: The participants indicated parents' involvement in the decision to vaccinate their children would motivate them to give vaccinations or offer education. The level of moral support and trust HCPs receive from the community and national leaders could influence HCPs to do more about HPV vaccination and education.
3. Reinforcing factors: Participants indicated that they would have the confidence to administer or talk to parents and adolescents about the vaccination if they know the vaccine works.

In addition to structural and administrative factors that could encourage or discourage the promotion of vaccine or vaccine education (e.g., transportation issue), the HCPs indicated that the kind of social support needed includes involvement of opinion leaders such as assemblymen, pastors, imams, and chiefs in leading HPV vaccination education efforts. However, they perceived that church involvement may be difficult since HPV vaccination may be thought of as encouraging immoral behaviours. The HCPs reported that the use of media such as radio and television programmes and church gatherings could encourage them and the community for HPV vaccines. The tangible support they need includes personnel, training and workshops, HPV vaccination kits, monetary incentives, and physical mobilisation of people in their communities for vaccinations. In addition, the HCPs cited phone calls, text messages, and volunteer visits to remind parents and adolescents as potential tools to increase HPV vaccination.

In conclusion, the study's findings underscore the need for a comprehensive HPV vaccination education programme for HCPs in Ghana. An intervention to increase knowledge about the safety and efficacy of the vaccine and to equip HCPs with strategies to communicate about the vaccine could help build the confidence of HCPs to counsel parents and adolescents. To address stigma about the vaccine, an intervention to reframe the conversation about the vaccination as cancer prevention may help to counter the narrative connecting the HPV vaccine and sexual behaviour. MTM constructs, including participatory dialogue, behavioural confidence, changes in the physical and environment, and sustenance could be used to guide future interventions to educate HCPs in Ghana about HPV vaccination.