HPV Vaccine Communication. Special considerations for a unique vaccine 2016 update

Transcription

1 HPV Vaccie Commuicatio Special cosideratios for a uique vaccie 2016 update

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3 HPV Vaccie Commuicatio Special cosideratios for a uique vaccie 2016 update

4 WHO/IVB/16.02 World Health Orgaizatio, 2017 Some rights reserved. This work is available uder the Creative Commos Attributio-NoCommercial-ShareAlike 3.0 IGO licece (CC BY-NC-SA 3.0 IGO; Uder the terms of this licece, you may copy, redistribute ad adapt the work for o-commercial purposes, provided the work is appropriately cited, as idicated below. I ay use of this work, there should be o suggestio that WHO edorses ay specific orgaizatio, products or services. The use of the WHO logo is ot permitted. If you adapt the work, the you must licese your work uder the same or equivalet Creative Commos licece. If you create a traslatio of this work, you should add the followig disclaimer alog with the suggested citatio: This traslatio was ot created by the World Health Orgaizatio (WHO). WHO is ot resposible for the cotet or accuracy of this traslatio. The origial Eglish editio shall be the bidig ad authetic editio. Ay mediatio relatig to disputes arisig uder the licece shall be coducted i accordace with the mediatio rules of the World Itellectual Property Orgaizatio.. Suggested citatio. HPV vaccie commuicatio. Special cosideratios for a uique vaccie: 2016 update. Geeva: World Health Orgaizatio; 2017 (WHO/IVB/17.02). Licece: CC BY-NC-SA 3.0 IGO. Cataloguig-i-Publicatio (CIP) data. CIP data are available at Sales, rights ad licesig. To purchase WHO publicatios, see To submit requests for commercial use ad queries o rights ad licesig, see Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your resposibility to determie whether permissio is eeded for that reuse ad to obtai permissio from the copyright holder. The risk of claims resultig from ifrigemet of ay third-party-owed compoet i the work rests solely with the user. Geeral disclaimers. The desigatios employed ad the presetatio of the material i this publicatio do ot imply the expressio of ay opiio whatsoever o the part of WHO cocerig the legal status of ay coutry, territory, city or area or of its authorities, or cocerig the delimitatio of its frotiers or boudaries. Dotted ad dashed lies o maps represet approximate border lies for which there may ot yet be full agreemet. The metio of specific compaies or of certai maufacturers products does ot imply that they are edorsed or recommeded by WHO i preferece to others of a similar ature that are ot metioed. Errors ad omissios excepted, the ames of proprietary products are distiguished by iitial capital letters. All reasoable precautios have bee take by WHO to verify the iformatio cotaied i this publicatio. However, the published material is beig distributed without warraty of ay kid, either expressed or implied. The resposibility for the iterpretatio ad use of the material lies with the reader. I o evet shall WHO be liable for damages arisig from its use. Prited i Switzerlad Photo credits: p.1: GAVI/S. Huq Omi; p.49: WHO/Y. Shimizu; p.51: WHO/PAHO; p.57: GAVI/D. Graham-Rowe. All other photographs are courtesy of C. McNab.

5 Cotets Ackowledgemets...iv Executive summary...v Itroductio: Special cosideratios for a uique vaccie...1 Who should use this guide?...3 The structure...3 PART I The basics: good commuicatio practices for immuizatio...5 Chagig huma behaviour: a process...6 Commuicatio priciples...7 The theory, reality ad eed to advocate for commuicatio...8 A ote o coutry cotext...9 The essetial elemets for commuicatio plaig...10 Sample HPV moitorig pla...18 Sample HPV commuicatio pla...20 PART II HPV vaccie: cosideratios for commuicatio...23 Why HPV vaccie is uique...23 Gettig started: what to cosider ad what to do...28 HPV vaccie i commuicatio plaig...32 Effective messages...40 Materials ad chaels...45 Crises...47 Coclusio ad summary...48 Coclusio...49 Summary: plaig ad cosideratios for HPV vaccie...50 Aex Crisis commuicatio for HPV vaccie...57 Be prepared...58 Implemet: whe crisis occurs...60 Cautios ad lessos from global experiece with HPV vaccie...64 FAQ, materials ad resources...66 Frequetly asked questios...67 Materials...72 Examples of HPV vaccie websites with sample materials...73 Resources...74

6 Ackowledgemets This guide is the result of the collaboratio ad hard work of may people. The World Health Orgaizatio s Immuizatio, Vaccies ad Biologicals Departmet commissioed ad provided oversight to its preparatio as part of a effort to cosolidate existig ad ew iformatio about HPV vaccie commuicatio. The sectio o the basics draws from several sources of previously published material ad from the author s experiece. A November 2015 WHO Global Learig meetig o HPV Vaccie Itroductio ad a 2015 review of HPV vaccie itroductios published by the Lodo School of Hygiee ad Tropical Medicie ad PATH iform this work. * Immuizatio programme maagers ad their teams i Latvia, Malaysia ad Rwada helped the author lear about ad uderstad the issues through field visits. WHO also thaks the health workers, headmasters, teachers, commuity leaders, mothers, fathers ad girls who took the time to share their thoughts, ad through this, help us do a better job. The origial 2013 versio of this guide ad this 2016 update were writte by Christie McNab. Paul Bloem, Tracey Goodma ad Susa Wag of WHO s Immuizatio, Vaccies ad Biologicals Departmet provided techical oversight. Scott LaMotage of PATH ad Abdelkader Bacha ad Joatha Shadid of UNICEF provided commets o the 2016 update. A short ote o termiology I this guide, commuicatio ecompasses the areas of advocacy, social mobilizatio, behaviour ad social chage ad crisis commuicatio. What is ew i this guide This updated versio of the guide reflects: 1. WHO s October 2014 chages to the recommeded HPV vaccie schedule. 2. Updated facts, evidece ad experiece from low, middle ad high-icome coutries that have itroduced HPV vaccie. 3. A ehaced sectio o crisis commuicatio. 4. Additioal iformatio about the opportuities for itegratio with comprehesive cervical cacer programs ad adolescet health itervetios ad o the coset process. * For the 2015 Lodo School of Hygiee ad Tropical Medicie/PATH review of HPV vaccie experiece across 37 low ad middleicome coutries, see iv

7 Executive summary This guide presets commuicatio guidace for coutries itroducig huma papillomavirus (HPV) vaccie at the atioal or sub-atioal levels. HPV vacciatio is a key strategy for comprehesive cervical cacer cotrol ad prevetio. By the ed of 2015, more tha 65 coutries itroduced HPV vaccie ito their atioal immuizatio programmes, with more tha 30 of them were approved for Gavi-supported itroductios. HPV vaccie presets some challegig issues for commuities. Cocers about the HPV vaccie are a commo feature of its itroductio. HPV vaccie is targetig girls before they become sexually active i order to prevet acquisitio of a sexually trasmitted ifectio (STI). WHO recommeds that two doses of the curretly licesed HPV vaccies be admiistered to 9 13-year-old girls to prevet ifectio with two types of huma papillomavirus that accout for about 70% of cervical cacer cases. The full beefits of HPV vaccie i reducig ifectio ad the subsequet risk of cervical cacer will oly be appreciated years ad eve decades after girls have bee vacciated. Coutries itroducig HPV vaccie should ivest i a commuicatio pla for the itroductio ad sustaied delivery of HPV vaccie so that it becomes positively associated with adolescet girls ad a socially-acceptable demaded service. This guide offers guidace i three mai areas: the first is advice o basic commuicatio plaig ad implemetatio for immuizatio; the secod discusses specific cosideratios for HPV vaccie; ad the third o crisis commuicatio. The basic elemets of a immuizatio commuicatio pla iclude: buildig a cross-sectoral team; clear programme ad commuicatio objectives; uderstadig commuity kowledge, attitudes ad practices; SMART objectives ad sesible strategies; defied target audieces with activities ad messages for each that use appropriate chaels ad materials; a crisis commuicatio pla to maage problems icludig adverse evets followig immuizatio; ad a moitorig ad evaluatio pla. The specific cosideratios of HPV vaccie draw o the experiece of coutries which have either itroduced the vaccie atioally or coducted demostratio projects, from parter experiece, as well as from several reviews ad evaluatios i low, middle ad high-icome coutries ad the published literature. This part icludes advice about cross-sectoral advocacy, team buildig ad formative research; coset; a descriptio of the recommeded target groups; the importace of careful plaig so that the messages reaches hard-to-reach girls; thoughts o itegratio with additioal services, ad advice about effective messagig, materials ad commuicatios chaels. May coutries itroducig HPV vaccie have faced specific challeges or crises that required commuicatio preparedess. The guide therefore icludes a sectio o preparig for ad implemetig a crisis commuicatio pla. Fially, the guide icludes summary tables, tips, frequetly asked questios, sample materials ad resources, all iteded to provide immuizatio maagers ad commuicatio specialists with the tools they eed to esure a high-quality strategic commuicatio pla. v

8 HPV Vaccie Commuicatio Special Cosideratios for a Uique Vaccie

9 Itroductio Itroductio Huma papillomavirus (HPV) vaccie has oe of the highest per-perso impacts o mortality of all vaccies. 1 First licesed i several high-icome coutries i 2006, the vaccie is beig steadily itroduced ito more coutries. The World Health Orgaizatio (WHO) recommeds vacciatio for 9 13-year-old girls as the most cost-effective public health measure agaist cervical cacer, as part of a comprehesive cervical cacer cotrol strategy. Give the vaccie s uique characteristics ad based o coutry experieces, WHO recommeds ivestmet i a commuicatio strategy for the itroductio of HPV vaccie. Low- ad middle-icome coutries, where more tha 85% of cervical cacer deaths occur, ca particularly beefit from HPV vaccie. By the ed of 2015 more tha 65 coutries itroduced atioal HPV vaccie programmes ad a umber of others had or plaed to itroduce pilot or demostratio programmes. The pace of itroductio i low-icome coutries eligible for support from Gavi, the Vaccie Alliace, is icreasig. More tha 30 coutries are approved presetly for GAVI-supported demostratio programmes ad atioal itroductios. Global ad coutry experiece i commuicatio for immuizatio cotiues to grow as coutries build o existig kowledge, add ew vaccies ad edeavour to icrease equitable coverage of atioal immuizatio programmes. Despite this experiece, challeges persist ad ew oes develop as the public health commuity struggles to egage some commuities ad families i immuizatio, leadig to suboptimal coverage. The lower uptake of some vaccies ca be caused by poor service delivery; a lack of kowledge about the threat of vaccie-prevetable 1. Lee L et al. The estimated mortality impact of vacciatios forecast to be admiistered durig i 73 coutries supported by the GAVI Alliace. Vaccie, 2013, Decade of Vaccies Supplemet, 2:B61 B72. Specifically, the reviews fids that First-dose measles, huma papillomavirus, ad hepatitis B vacciatio are expected to have the highest per-perso impact ad avert 16.5, 15.1, ad 8.3 deaths per 1000 persos vacciated, respectively. 1

10 HPV Vaccie Commuicatio: Special cosideratios for a uique vaccie 2016 update diseases, the risks ad beefits of vaccies; complacecy; mistrust of govermet, health workers ad maufacturers; ad alterative health or religious beliefs. These challeges uderscore the importace of early itegratio ad ivestmet i a strategic commuicatio pla icludig a crisis commuicatio pla for immuizatio programmes. There is a growig body of kowledge ad iformatio o HPV vaccie commuicatio. I most low- ad middle-icome coutries, demad ad coverage with HPV vaccie is high. While HPV vaccie presets excitig opportuities for public health, experiece reveals commuicatio challeges i some coutries ad commuities. People mistrust it because it is ew ad is mistake for a experimetal vaccie, targeted oly at youg adolescet girls, or they believe it will lead to icreased sexual activity. I some coutries, paediatricias, gyaecologists or religious leaders have misuderstood the purpose or value of HPV vaccie, leadig to resistace ad low coverage. I a hadful of coutries, HPV vaccie has bee rejected due to misiformatio. This guide summarizes good practices for HPV vaccie commuicatio based o material from several sources, icludig coutry ad parter experieces, the fidigs of coutry reviews; recogized best practices for commuicatio, advocacy ad social mobilizatio for public health; ad learig from other relevat programme ad parter experieces. 2

11 special cosideratios Who should use this guide? This guide should be read together with WHO s Pricipals ad cosideratios for addig a vaccie to a atioal immuizatio programme: From decisio to implemetig ad moitorig ad WHO s HPV Vaccie Itroductio Guide. 2 Natioal immuizatio maagers, atioal ad district social mobilizatio teams, parters ad iteratioal agecy staff ivolved i HPV vaccie itroductio ca use this guide to pla ad implemet a commuicatio strategy for HPV vaccie itroductio ad its sustaied delivery. Additioal parters ivolved i cervical cacer cotrol, reproductive health, adolescet health, wome s health ad other critical sectors such as educatio will also beefit from this guide. Readers may also wish to cosult resources o commuicatio for immuizatio, health programmig, cervical cacer, adolescet, sexual ad reproductive health. Some key resources are listed at the ed of this documet. The structure special cosideratios for a uique vaccie Part I THE BASICS Describes good public health commuicatio practices ad priciples applicable to ay coutry health commuicatio programme. Part II HPV VACCINE HPV VACCINE: focuses o why HPV vaccie merits additioal cosideratios, ad describes key features coutries should build ito their HPV vaccie commuicatio plas. Cosideratios for commuicatios Crisis commuicatio for HPV vaccie coclusio ad summary Summary tables: a sample commuicatio pla, diagrams ad tips boxes throughout the documet help guide the reader to the most importat cotet. aex: crisis commuicatio faq, materials ad resources Frequetly asked questios: offers basic guidace to aswer commo questios about HPV vaccie. Materials ad resources: icluded at the ed of the report for referece ad further study. 2. See ad 3

12 HPV Vaccie Commuicatio part I: The Basics

13 Itroductio Good commuicatio practices for immuizatio Immuizatio should be a social orm, wherei the demad for ad access to immuizatio for all members of every commuity is ormal, socially acceptable health behaviour. The itroductio of HPV vaccie should be approached as a log-term ogoig strategy to help prevet cervical cacer, ad commuities should demad it as a social orm for their adolescet girls. Strategic commuicatio will help to create that orm. The itroductio of HPV vaccie should be approached as a log-term ogoig strategy to help prevet cervical cacer, ad commuities should demad it as a social orm for their adolescet girls. Commuicatio theories posit that people udergo a process to reach a decisio to take a ew actio or to chage a behaviour. 3 This process usually begis with a perso who is uaware of a itervetio such as vacciatio. Through commuicatio activities, they become aware, cosider the itervetio, adopt the itervetio, repeat ad demad it, ad promote the itervetio to their commuity. Strategic commuicatio ad egagemet are a key parts of this process, alog with the provisio of high quality, accessible ad reliable health services. This is a iterative process that ca take time. 3. The differet commuicatio theories ad approaches are documeted ad explaied i other literature ad will ot be repeated here. For more o commuicatio theories such as COMBI ad C-Chage, see the articles ad resources listed o the Commuicatio Iitiative s website: For iformatio ad resources o Commuicatio for Developmet (C4D) see UNICEF s website: 5

14 HPV Vaccie Commuicatio: Special cosideratios for a uique vaccie 2016 update Chagig huma behaviour: a process People geerally udergo a iterative process towards takig a ew actio or chagig a behaviour. Chagig huma behaviour: a process People geerally go through a iterative process towards takig a ew actio or chagig a behaviour. Be completely uaware 2 of HPV vaccie Proactively have her secod daughter vacciated 5 1 May factors play a role i the success, icludig the perceptio of threat of HPV ad cervical cacer, the degree to which she trusts the vaccie, the message ad its source, what actio frieds ad family are takig ad access to the HPV vaccie. 4 Gai awareess through commuicatio 3 Cosider HPV vaccie based o kowledge gaied from several sources Take actio to have her daughter vacciated For example, over time a paret or caregiver may: 1. Be completely uaware of HPV vaccie. 2. Gai awareess through commuicatio activities. 3. Cosider acceptig HPV vaccie based o kowledge gaied from several sources. 4. Take actio to have their daughter vacciated. 5. Proactively take their secod daughter for vacciatio. 6. Promote HPV vaccie i their commuity. May factors play a role i the caregiver s decisios, icludig uderstadig cervical cacer, the perceptio of risk of HPV ifectio, the degree of trust i the vaccie, the sources of iformatio ad the messages, the actios of frieds ad family ad the daughter s access to the HPV vaccie. 6

15 PART I: THE BASICS Commuicatio priciples Health commuicatio should adhere to key priciples ad be grouded i a huma rights approach. 1. Promote commuity egagemet Oe goal of primary health care is for commuities to ow ad demad the health programme or itervetio. This ca take time. Withi commuities, there will be may voices some actively supportive, others passively acceptig ad some actively opposed. Commuicatio should idetify ad egage all groups, their leaders ad other ifluecers. It is huma ature to wat to lear, challege assumptios ad ask questios. Iterpersoal commuicatio ad commuity participatio will be key to successful commuicatio. Over time this will produce improved, more sustaiable health behaviours ad outcomes. 2. Promote equity Good public health practice is to esure all people who eed a itervetio are reached. Yet, oe i five childre are ot receivig the vaccies they eed. May of these are margialized ad hard-to-reach populatios. Sometimes these populatios do ot kow a service is available, laguage barriers create misuderstadigs, or a supportive eviromet is abset. Commuicatio strategies should aim to reach the ureached families who may be day labourers, migrats, omads ad miority groups. Reachig uvacciated childre icludig adolescet girls protects these commuities, ad is essetial to achieve immuizatio ad cervical-cacer cotrol goals. Commuicatio for Developmet Priciples Uited Natios agecies geerally promote Commuicatio for Developmet or C4D, a participatory process usig advocacy, social mobilizatio, ad social ad behavioural chage activities to empower idividuals ad commuities to take actios ad improve their lives. C4D promotes the followig priciples: Create spaces for a plurality of voices, promote arratives of commuities, ecourage listeig, dialogue ad debate ad the meaigful participatio of childre ad wome. Iclusio, self-determiatio, participatio ad respect by esurig that margialized ad vulerable groups are prioritized ad give visibility ad voice. Lik commuity perspectives ad voices with sub-atioal ad atioal policy dialogue. Address the whole perso icludig the cogitive, emotioal, social ad spiritual aspects i additio to survival ad physical developmet. Build the self-esteem ad cofidece of parets, care providers, adolescets ad childre. 7

16 HPV Vaccie Commuicatio: Special cosideratios for a uique vaccie 2016 update The theory, reality ad eed to advocate for commuicatio Strategic commuicatio requires ivestmet. Successful public health ca be equated to a threelegged stool. Oe leg is availability of the itervetio itself (e.g. the vaccie ad logistics); the secod is a traied, motivated cadre of health persoel; ad the third is public acceptace ad demad. Without the last elemet, the ivestmet i the vaccies, logistics ad health-worker traiig is wasted. HPV vaccie may be available, but if the populatio does ot uderstad what it is for ad why it beefits them, they will ot automatically demad it. Worse, they may begi believig misiformatio about it. All of the elemets described i the previous sectio represet the ideal for commuicatio plaig ad implemetatio. However, experiece shows that the ideal is sometimes far from possible. I reality, health departmets may have oe or two commuicatio/social mobilizatio officers workig simultaeously o multiple projects. Exteral parters might also be equally stretched. The time required to take all of these steps may ot be available. Ofte, the situatio aalysis is doe too rapidly with isufficiet iformatio. A atioal KAP survey may require several moths to complete, while the programme may be scheduled to begi earlier. Fudig may arrive late, seriously disruptig the pla. SMART objectives may have all bee deemed priorities but were i reality too umerous to achieve. Staff workig o the project may have persoal family matters that require their exteded time away from work. Commuicatio activities are ofte uder-resourced, but to achieve success i a public health programme, it is importat to advocate for icreased resources. Plaig is oe way to make the ivestmet case. A thoughtful commuicatio pla which demostrates, with evidece, how it will cotribute to better public health outcomes is more likely to attract resources tha a pla that proposes oly IEC materials. Immuizatio programmig ca beefit from the umber of parters ivolved i the commuicatio workig group. Get them ivolved early. Elist their support to help with the situatio aalysis ad the developmet of evidece-based plas. The preferred result is a persuasive commuicatio pla with the resources required to achieve the desired public health outcomes. 8

17 PART I: THE BASICS A ote o coutry cotext Some coutries may ot require as much ivestmet i additioal commuicatio. Coutries where public cofidece i govermet programmig is high ad where clear commuicatio systems from atioal to commuity level may be able to use existig structures to commuicate effectively about a ew public health programme. People will accept ad eve demad the vacciatio because they trust their leaders to offer health itervetios that beefit commuities ad the coutry. A ote of cautio: with icreasig access to the Iteret, much more iformatio is available rapidly tha previously. This icludes misiformatio about HPV ad other vaccies. The iformatio may look official ad cite researchers ad other scietists. Ati-vacciatio groups ca make a compellig case to a utraied perso who may already have questios about vaccies. Rumours ca begi quickly i commuities ad be amplified atio-wide through mobile phoes, iexpesive videos ad social media tools. Therefore, it is importat to esure that, eve i coutries with high public trust ad established commuicatio systems, clear iformatio i lay laguage is available to all target audieces icludig commuity leaders. Clear iformatio ca iclude: A cover letter to commuity leaders accompaied by a simple, cocise questio ad aswer documet that helps commuity leaders explai HPV vaccie. Traiig ad iformatio, educatio ad commuicatio (IEC) materials for health workers so they uderstad the itervetio ad ca commuicate clearly ad cofidetly with the commuity. Usig the Iteret to dissemiate iformatio. Some coutries have established specific HPV vaccie websites i local laguages that offer facts, aswer commo questios, address rumours ad provide copies of IEC ad media materials for easy dowload. As a referece, the World Health Orgaizatio s diseases provides updated iformatio about HPV, cervical cacer ad all other vaccie prevetable diseases. 9

18 HPV Vaccie Commuicatio: Special cosideratios for a uique vaccie 2016 update The essetial elemets for commuicatio plaig A HPV vaccie commuicatio pla icludes the followig basic elemets. 1. A commuicatio team Coutries geerally assemble a team to work o commuicatio for a health programme or itervetio. This team, whether a sub-committee or workig group, will be a key part of the larger plaig team that may iclude operatios, procuremet, logistics ad overall maagemet. The team should iclude commuicatio experts from govermet ad relevat parter orgaizatios ad represetatio from the differet sectors ivolved i the programme, such as youth ad educators. 2. Techical programme objectives The commuicatio strategy must support achievemet of the techical programme objectives. I the case of HPV vaccie, this may be to achieve > 70% coverage of the target populatio i year 1, > 80% i year 2, while reachig > 75% of hard-to-reach girls ad icreasig awareess of cervical cacer screeig to cotribute to the achievemet of cervical cacer cotrol goals. 3. Situatio aalysis A situatio aalysis forms the foudatio for all commuicatio plaig ad makes it possible to pla ad budget for high-impact activities. It also provides the baselie agaist which to measure progress. A situatio aalysis takes time ad huma ad fiacial resources to do well but without ivestmet i this step, commuicatio efforts ad fuds may be wasted o the wrog audieces with the icorrect messages ad activities. The situatio aalysis should examie: Existig data sources icludig surveys (e.g. multiple-idicator cluster surveys (MICS) ad demographic health surveys (DHS), immuizatio coverage surveys, school erolmet). Immuizatio programme iformatio icludig reviews, admiistrative data, moitorig data. Kowledge, attitudes, practices (KAP) surveys ad behavioural aalyses of the mai audieces. Reports from media, doors ad other parters. Maps icludig social ad satellite maps. If there is isufficiet existig iformatio, formative research may be ecessary. This ca rage from large KAP surveys to smaller samples icludig key iformat iterviews ad focus group discussios i the target populatio. 10

19 PART I: THE BASICS 4. SMART commuicatio objectives Based o the situatio aalysis, set SMART commuicatio objectives that will express the specific ways i which commuicatio activities ca help to deliver the techical programme objectives. SMART is a acroym that meas specific, measurable, attaiable, results-orieted, ad time-boud. Example: Parter with the educatio sector so that teachers ca provide three key messages about HPV vaccie to target age girls 10 days before the vaccie s itroductio. Tips»» Objectives should be realistic. Esure they are ot too ambitious ad ca be achieved i the time allotted.»» Prioritize the umber of SMART objectives do ot set so may that they become overwhelmig ad uattaiable. 5. Target audieces Kowig the target populatio will help to esure the right messages, materials, activities ad laguages. Tips»» For some itervetios the target audiece may be quite broad for example health workers or target-age girls.»» For others, it may be very specific: perhaps the director of health i oe state or provice or the presidet of a associatio. 6. Defie messages for each audiece Differet audieces will respod to differet messages. While there may be some commo messages (e.g. x disease is dagerous ad ca be preveted), a health miister will be coviced by differet iformatio tha a fiace miister, ad a mother may eed differet iformatio tha a health worker. Messages should: target the audiece, be simple ad easy to uderstad; o jargo, ad iclude a call to actio. Ideally, messages should be based o a message map for each audiece. The example below provides key messages ad the supportig facts. These messages ad facts form the basis for all commuicatio materials, icludig brochures, media campaigs ad traiig materials. 11

20 HPV Vaccie Commuicatio: Special cosideratios for a uique vaccie 2016 update Stakeholder/Audiece: rural female caregivers Situatio aalysis: 90% of rural female caretakers surveyed kow othig about cervical cacer or HPV vaccie SMART Objective: more tha 65% of rural female caretakers kow three messages about HPV vaccie before the 2d dose is admiistered Key Message 1: HPV vaccie protects girls from most cervical cacer. Key Message 2: HPV vaccie is safe ad effective. Key Message 3: Protect your girls! Make sure all grade 6 girls receive two doses of HPV vaccie. Supportig Fact 1.1 Cervical cacer is a leadig cause of cacer i wome i this coutry. Supportig Fact 1.2 HPV vaccie protects agaist ifectio with HPV types that cause 70% of cervical cacer. Supportig Fact 1.3 Research shows a declie i HPV ifectios i populatios where HPV vaccie has bee itroduced. Supportig Fact 2.1 Health workers are traied to provide HPV vaccie safely. Supportig Fact 2.2 HPV vaccie is delivered with a auto-disable (AD) syrige that is used oly oce ad the safely disposed. Supportig Fact 2.3 May studies coducted i developig ad developed coutries have foud HPV vaccie to be safe ad effective. Supportig Fact 3.1 The govermet immuizatio schedule recommeds two doses of HPV vaccie for target age girls spaced six moths apart (or ot more tha moths apart). Supportig Fact 3.2 Two doses are recommeded by WHO to give optimum protectio. Supportig Fact 3.3 The exceptio are girls who are receivig HPV vaccie for the first time at age 15 or older, or girls who are immuo-compromised (e.g. HIV+). These girls require three doses. Tip»» Test the messages with the audieces. Rapid focus groups ca help to esure that people uderstad the messages ad kow what actio to take. 12

21 PART I: THE BASICS 7. A mix of strategies, activities ad chaels to reach the audieces These should directly support achievemet of the commuicatio objectives. Audieces will be reached ad egaged through a mix of strategies, activities ad chaels. Strategies are the approaches take to achieve objectives ad iclude advocacy, social mobilizatio, social ad behaviour chage, ad crisis commuicatio. Activities are the actios take to support a strategy ad ca iclude, for example, advocacy meetigs, creatig strategic parterships, discussios betwee the health worker ad caretaker, publishig iformatio materials ad hostig media evets. Chaels are the ways i which a message reaches the audiece, ad ca iclude ifluecers such as a health worker, family member, religious or political leader, the mass media or social media. Differet audieces respod to differet strategies, activities, ad chaels. For example: A high-level advocacy meetig betwee the health team ad fiace miister may be the key activity required to remove a fudig bottleeck. A mother may eed to be reached through several chaels icludig a TRUST, INFLUENCE ad CHANNELS Oce audieces are idetified, coduct a chael aalysis to determie what iformatio chaels will be most ifluetial with the specific audiece. People are more likely to believe iformatio from sources they trust. The commuicatio pla should cosider each chael of iformatio ad prioritise those that are the most trusted ad have the widest reach withi that audiece. For may people, govermet edorsemet is importat. Cosider which radio programmes ad ewspapers people trust the most. Trusted seior health practitioers ca be good spokespeople. Cosider egagig a beloved actress who has daughters she will have vacciated. I additio, cosider miority groups who may trust differet sources. popular health radio programme, iterpersoal commuicatio with her trusted health worker, through a sermo at the church or a mosque aoucemet, ad through the educatioal system, such as a letter to parets from the school headmaster. Differet strategies ad activities have very differet cost implicatios For example: Televisio typically costs the most ad may oly reach those wealthy eough to ow televisios. Mobilizig a trusted commuity-based orgaizatio to commuicate about the programme i every village is also costly but may have more impact o paretal demad ad acceptace. 13

22 HPV Vaccie Commuicatio: Special cosideratios for a uique vaccie 2016 update 8. Create braded materials The strategies ad activities will have a bearig o the package of materials required. Materials should be tailored to the audiece, ad should be braded i a uiform way. They should iclude govermet ad parter logos. Examples of materials iclude: Advocacy presetatios. A list of key messages. Frequetly asked questios (FAQs). Issues maagemet advice. Iformatio, educatio ad commuicatio materials (leaflet, posters, flipcharts). Traiig materials for health workers ad teachers. A media kit for jouralists. Factors to cosider: Materials should be clea, simple ad legible. For o-specialists, materials should use images, simple graphics ad fewer words. Materials should have a commo look ad brad, use a uifyig logo, colour, type fot ad desig scheme, together with govermet ad parter logos. Pre-test the materials with the target audieces for appeal, relevace, comprehesio, acceptability, persuasio ad recall. I practical terms, a coutry team might test messages ad materials at the same time. Use HPV vaccie materials to iclude short complemetary messages about cervical cacer screeig, adolescet health or routie immuizatio. Create a distributio pla so materials arrive i the right place o time. Iclude electroic distributio by , through the Iteret ad through social media where available. Tips»» Is the laguage ad artwork appropriate for illiterate populatios or laguage miorities?»» Are the physical depictios of people culturally appropriate, icludig for miorities?»» Is there a clear call to actio?»» How is the prit quality? It ca be temptig to save moey by pritig with low-quality ik ad paper, but if the material fades or tears quickly, it may be moey wasted.»» Will the material really be used? Posters, for example, ca work well i a coutry where health cliics or schools routiely hag posters i a visible locatio, but ot where distributio is poor or there is a lack of practical hagig tools such as sticky tape or thumb tacks. 14

23 PART I: THE BASICS 9. A crisis commuicatio pla HPV vaccie has bee subject to rumours ad liked with adverse evets followig immuizatio (AEFI) i may coutries. Complacecy, misiformatio, adverse evets ad a lack of cofidece i health systems ca lead to a crisis i immuizatio programmig, quickly erodig trust i EPI icludig HPV vaccie. 4 Recovery from such a crisis ca take years ad ca lead to extremely low immuizatio coverage rates over a prologed period of time. Crisis preparatio ad maagemet ca avert costly problems. The rise of Iteret access ad social media meas that iformatio facts ad rumours, celebratio ad scares - ca spread more quickly tha before. Evets or public perceptios i other coutries eve other cotiets ca have a impact o people s uderstadig of ad trust i vaccies. People who have questios, mistrust the health establishmet ad/or favour homeopathic medicie will fid lots of iformatio o the Iteret that supports their views, ad ca spread this iformatio through their social etworks. This misiformatio ca result i greater risk of a crisis if there is a serious AEFI, icludig those that tur out to be urelated to vacciatio. 5 The Global Vaccies Safety Blueprit recommeds that every coutry develop a vaccie safety commuicatio pla as part of a itegrated commuicatio pla, aimed particularly at commuities, health care workers ad decisio-makers. The Blueprit stresses that ay vaccie safety cocers should be ivestigated ad promptly commuicated appropriately. 6 Crisis commuicatio for health has become more evidece-based over time with experiece draw from misiformatio related to HPV ad measles-mumps-rubella, Severe Acute Respiratory Sydrome, H1N1, multiple crises i polio eradicatio, Ebola i west Africa, ad other health emergecies. For more o crisis commuicatio, see page 57 of this guide. 4. There are several examples listed i Buildig Trust ad Respodig to Adverse Evets Followig Immuizatio i South Asia: Usig Strategic Commuicatio, UNICEF ROSA, For more o AEFI surveillace, icludig ivestigatio, aalysis ad commuicatio, see theglobal Maual o Surveillace of Adverse Evets Followig Immuizatio; WHO, 2014, 6. World Health Orgaizatio: Global Vaccie Safety Blueprit;

24 HPV Vaccie Commuicatio: Special cosideratios for a uique vaccie 2016 update 10. A moitorig ad evaluatio pla Commuicatio-specific outcomes ca be difficult to measure as commuicatio efforts ted to cotribute to overall programme outcomes. Noetheless, the commuicatio pla should iclude moitorig ad evaluatio compoets. Implemetig a moitorig pla with clear idicators ca determie whether the pla is o track ad focus o where to make adjustmets. It will form the basis of reports to programme maagers, oversight bodies ad doors. A mid-term or ed-of-project evaluatio will highlight project challeges ad outcomes ad ca make recommedatios to guide future programmes i the coutry ad globally. A moitorig ad evaluatio pla requires cotemplatio about objectives, targets ad milestoes, together with idicators ad methods to assess the pla s outcomes. Set overall targets based o the SMART objectives to track progress ad achievemets. Example By Year 3: > 90% of teachers of target age girls kow why girls should be vacciated. > 75% of caregivers ca describe how to prevet cervical cacer. > 80% of hard-to-reach girls kow where to access HPV vaccie. Set milestoes as iterim goals towards achievemet of the pla. Example By year 1: 100% of health workers i 6 districts are traied i iterpersoal commuicatio. 75% of caregivers report they have atteded a commuity meetig about HPV vaccie. Set idicators icludig iput, output/process ad outcome - agaist which to measure progress. Iput idicators: track the resources or iputs ivested ito the programme (e.g. staff, voluteers, fuds, equipmet) Examples: Number of staff hired o time. Percetage of fuds released by a certai date. Number of documets produced o time. 16

25 PART I: THE BASICS Output/process idicators: track the activities ad products completed (e.g. traiig workshops, commuity meetigs held, radio aoucemets aired). Examples: Number of iterpersoal commuicatio traiig workshops held at district level o time. Number of radio aoucemets aired o radio prior to itroductio. Number of IEC packages delivered to health cetres o time. Outcome idicators: track the results or chages i the target populatio as a result of the activity. Examples: % of teachers who kow three key messages about HPV vaccie. % of caregivers who cite health workers as the source of iformatio about HPV vaccie. % chage i vaccie uptake i a formerly vaccie hesitat area. For example, coverage surveys should iclude questios about source of iformatio that ca reveal whether commuities are learig about HPV vaccie through the chaels prioritized i the commuicatio pla, reasos for acceptig vacciatio that ca show whether commuicatio played a role ad reasos for o-vacciatio that may ucover the circulatio of rumours or other problems. 7 Ideally, a idepedet exteral evaluatio should be part of the pla ad budget. If this is ot possible, a hoest iteral evaluatio with parters could also be scheduled. I order to assess outcomes, a programme may require a larger survey (such as a KAP survey) or use differet sources of iformatio icludig key iformat iterviews, coverage surveys, post-itroductio evaluatios, rapid exit surveys, programme moitorig, reports ad iformatio published i the media. Tips Moitorig idicators require:»» A baselie to kow the startig poit agaist which to measure progress.»» Settig priorities: do ot moitor everythig. Pick thigs that are realistic to moitor ad will demostrate progress ad challeges.»» A validatio source: e.g. from supervisory reports, rapid surveys, mothly reportig.»» A frequecy for validatio: e.g. quarterly.»» Icorporatio ito existig EPI reportig tools as much as possible such as admiistrative reportig tools, coverage surveys, or post-itroductio evaluatios. 7. Waisbord et al. examie real-time commuicatio moitorig i Commuicatio for polio eradicatio: improvig the quality of commuicatio programmig through real-time moitorig ad evaluatio. Joural of Health Commuicatio. 2010, 15 Suppl 1:

26 HPV Vaccie Commuicatio: Special cosideratios for a uique vaccie 2016 update Sample HPV moitorig pla SMART objective / Target Withi three years, 90% of teachers of target age girls kow three key messages about HPV vaccie Activity Aual teacher orietatios Baselie 10% of teachers kow why girls should be vacciated Idicators Iput idicator Number of iformatio leaflets prited per teacher Validatio: Commuicatio team reports Frequecy: Oe per year Output idicator Percetage of teachers attedig orietatio meetigs Validatio: Orietatio sig-i sheets ad teacher registries Frequecy: Oe per district per year Outcome idicator Percetage of teachers who ca provide three key messages about HPV vaccie Validatio: Survey Frequecy: Oe per year with HPV vaccie moitorig 11. A work pla with a budget Oce the essetial elemets of the commuicatio strategy are mapped, itegrate them ito a work pla. The work pla should iclude a list of activities, the resposible perso, the fuds required for each elemet, the deadlie for each activity ad space for status reports. The work pla ad budget may eed to be authorized by the atioal programme coordiatio group. 18

27 PART I: THE BASICS 12. Adjust the work pla as required Commuicatio is a cotiuous process, with the goal of esurig HPV vacciatio becomes a social orm. The pla will eed refiig as the programme cotiues. If moitorig ad other reports idicate a activity is ot workig as aticipated, it should be stopped or adjusted. Ivestmets i commuicatio may chage over time as a programme becomes more itegrated ito the commuity ad accepted as a regular part of health programmig. 19

28 HPV Vaccie Commuicatio: Special cosideratios for a uique vaccie 2016 update Sample HPV vaccie commuicatio pla Programme objective Achieve more tha 90% coverage of Grade 5 girls ad 10-year-old out-of-school girls with two doses of HPV vaccie this caledar year. Situatio aalysis I the majority populatio I most of the coutry, 10% of target-age girls are ot i school, for a total of girls. Based o demographic surveys ad kowledge of the culture, about 80% of out-of-school girls are helpig i the home, ad 20% are workig i the family busiess (shops, street stalls, small restaurats). Commuity attitude towards immuizatio is positive (e.g. DTP3 = 87%). A ew commuity survey shows that 60% of female caregivers kow very little or othig about cervical cacer ad that 90% of female caregivers kow very little or othig about HPV ad HPV vaccie. Previous experiece i the coutry shows that these caregivers trust the First Lady ad primary health-care workers. Almost every commuity listes to the 18:00 atioal ews o the radio. I the miority populatio I six districts of x Provice, more tha 80% of target-age girls are ot i school, comprisig target-age girls. They maily work o their family farms. Commuity attitudes about immuizatio are less positive (e.g. DTP3 = 70%). The commuity survey shows that 80% of female caregivers kow very little or othig about cervical cacer ad that almost 100% of female caregivers kow very little or othig about HPV ad HPV vaccie. Previous experiece shows that this commuity mistrusts the govermet but trusts their religious leaders ad midwives. 20

29 PART I: THE BASICS Sample commuicatio pla SMART objective 80% of caregivers ca aswer three basic questios about cervical cacer ad HPV vaccie by the ed of the year. Target audieces 1. Caregivers of Grade 5 girls, ad 10-year-old out-of-school girls i the majority populatio Messages Cervical cacer is a leadig cause of death for wome i our coutry. A virus called huma papillomavirus, which is trasmitted through sexual activity, causes cervical cacer. Most wome will get this virus whe they are youger. Some will develop cervical cacer. We are offerig a safe, effective vaccie that will prevet most cervical cacer. All Grade 5 girls i school, ad 10-year-old girls ot attedig school should be vacciated. Protect your daughters. Be sure they receive 2 doses of the cervical cacer vaccie this year. Strategies, activities, & chaels Advocacy: with First Lady ad ask her to lauch HPV vaccie oe week before itroductio. Social ad behavioural chage with commuity: HPV vaccie commuity iformatio sessio i every catchmet area. Social ad behavioural chage through radio media: public service aoucemet to ru before the 18:00 atioal ews every day for two weeks before ad durig the week of itroductio. 2. Caregivers of 10-year-old girls i miority populatio i x Provice. Messages Same as above with these additios: HPV vaccie is safe ad is used i eighbourig coutries, Brig your 10-year-old girls to discuss the HPV vaccie with your commuity midwife, ad have her vacciated. Strategies, activities, & chaels Social ad behavioural chage: orietatio meetig with with midwives ad religious leaders. Midwives lead commuity iformatio sessios with religious leaders preset i all catchmet areas. Materials 1. Braded promotioal materials for lauch. Lauch speech for First Lady. 2. Traiig package icludig iterpersoal commuicatio (IPC) skills for all health workers ad teachers resposible for immuizatio. 3. Package of IEC materials (poster, leaflet) to be used at commuity iformatio sessios. 4. Three versios of the public service aoucemet. 5. Same as above i local laguage. 6. Orietatio package for midwives ad religious leaders. Targets 1. Lauch covered o all major media % of commuity meetigs held % of people surveyed cite PSA as a source of iformatio. Idicators Iput: % of IEC materials arrived i time for the health iformatio sessio. Process: % of commuity iformatio sessios held. Outcome: % of caregivers who ca aswer three basic questios about HPV vaccie ad cervical cacer. Note: this is ot a comprehesive pla, ad data ad iformatio have bee created oly for the purpose of this exercise. 21

30 HPV Vaccie Commuicatio part II: HPV Vaccie

31 Itroductio Cosideratios for commuicatio This sectio outlies the elemets of the commuicatio plaig process discussed i the last sectio ad idetifies key cosideratios for the itroductio of HPV vaccie. The sectio also looks at broader, commo lessos that have emerged from low-, middle- ad high-icome coutries. Why HPV vaccie is uique HPV vaccie is differet i several ways from other ew vaccies targeted at ifats. Characteristics of HPV vaccie Potetial commuicatio issues Targeted at pre-adolescet ad adolescet girls May be i or out of school; if out of school, harder to reach. Cocers about girls fertility ad sexual activity. Cocers about why the vaccie is ot available to all wome or to boys ad me. A ijected vaccie Fear of ijectios amogst target-age groups. Higher risk of mild AEFIs icludig faitig. 23

32 HPV Vaccie Commuicatio: Special cosideratios for a uique vaccie 2016 update Characteristics of HPV vaccie A ewer vaccie A relatively expesive vaccie Potetial commuicatio issues (cotiued) Cocers about safety, side-effects ad efficacy, or experimetatio. Cocers about maufacturig origi; whether it meets religious stadards (e.g. halal). Cocers from health professioals, icludig gyaecologists, about budget priorities. Provided i a two-dose schedule i a six-moth (or moth) timeframe Maitaiig support of schools for multiple health worker visits. Reachig girls who drop out, chage or are ot i school with both doses. Protects agaist HPV a little-kow sexually trasmitted ifectio Explaiig HPV ifectio risks ad prevalece i clear, o-judgmetal ad culturally appropriate terms. Not cofusig with HIV or other sexually-trasmitted ifectios. Protects agaist cervical cacer which maifests years after HPV ifectio Cervical cacer may ot be well-kow or easily discussed. Gaiig ad maitaiig support whe the beefits of HPV vaccie may ot be see for several years, ulike vaccies agaist outbreak-proe vaccie-prevetable diseases like measles. Protects agaist 70% of cervical cacers a Explaiig that it does ot protect agaist all causes of cervical cacer. Explaiig that cervical cacer screeig is still ecessary. Explaiig that cervical cacer screeig is ecessary but may ot be widely available a. Of iterest to several disciplies ad sectors Opportuity to ivolve immuizatio, child health, adolescet health, HIV/STIs, cacer, sexual ad reproductive health ad educatio parters. Opportuity to itegrate commuicatio strategy ad messagig with several areas icludig cervical cacer prevetio, adolescet health, educatio ad others. a. By July 2016, WHO had prequalified bivalet- ad quadrivalet-hpv vaccies, which protect agaist 70% of cervical cacers. A 9-valet HPV vaccie, which protects agaist up to 90% of cervical cacers was uder review for pre-qualificatio by WHO. 24

33 part II: HPV Vaccie Coutry experiece: sapshots Coutries have leared several lessos about commuicatio for HPV vaccie itroductio. Here are a few excerpts of reported experieces, both positive ad challegig. Most of these experieces were reported at the November 2015 WHO Global Learig meetig o HPV Vaccie Itroductio. Importace of mappig stakeholders ad buy-i Oe Europea coutry experieced high resistace from several health associatios, which publicly braded itroductio of HPV vaccie as too expesive. Their resistace sparked additioal questios ad cocers from health workers ad parets, ad cotributed to low coverage. Oe Africa coutry was surprised whe the huma rights commissio which was ot ivited to the iitial stakeholder meetigs threateed to sue the govermet as it had misuderstood HPV vaccie to be a experimetal ew itervetio that might damage girls fertility. Days before implemetatio the coutry immuizatio maager had to act quickly ad meet with the commissio to explai the purpose ad safety of HPV vaccie. A souther Africa coutry says oe of the biggest success factors for itroducig HPV vaccie was ivolvig paret teacher associatios ad teachers uios. They could mobilize girls for immuizatio ad help solve problems reachig school girls. Cosiderig Coset Coutries use differet approaches to coset, ragig from more formal, writte or verbal coset to more iformal, implied coset procedures betwee health workers ad caregivers. These provide both opportuities ad challeges. Oe South-East Asia coutry successfully uses a writte coset form that is set home to parets for sigature. Without writte coset, girls are ot vacciated. The form also icludes a AEFI checklist for parets to report eve mild adverse effects to the health system. Other coutries use implied coset where all caregivers are ivited to a commuity iformatio or paret teacher associatio meetig ad iformed about HPV vacciatio. The health workers the cosider that coset has bee give for all girls that come for vacciatio i the commuity or school. Several coutries report that by ot seekig formal coset for routie immuizatio, some commuities became suspicious whe this was itroduced for the HPV vaccie, ad wodered whether the vaccie was experimetal. May coutries ote that regardless of the coset process used i public schools, private schools ted to isist o opt-i coset forms distributed to every girl ad siged by caregivers. 25

34 HPV Vaccie Commuicatio: Special cosideratios for a uique vaccie 2016 update Workig with traditioal ad religious leaders Coutries report there are several examples of how workig, or ot workig with religious leaders affected the acceptace of the HPV vaccie. Oe Africa coutry reports that it made a special effort to egage the Chief of a district, who was also the head religious leader. The good ews was that all of his followers brought their girls for HPV vaccie immuizatio. The challege was they had ot egaged the miority religious leader i the area. The result? His followers did ot brig their girls for vacciatio. The lesso: egage religious ad traditioal leaders who will appeal to differet populatios i the commuity. Oe South-East Asia coutry s religious leaders issued a Islamic fatwa atioally, declarig the HPV vaccie to be safe ad importat for girls health. Messages ad Materials Coutries report it is importat to keep messages simple ad jargo-free. However, may stress the importace of creatig differet types of iformatio packages for differet audieces. This icludes more sophisticated messagig for media that, for example, will address cocers people may have read o the Iteret. Multiple laguages Other coutries report that traslatio is essetial for each laguage group. Cosistecy across materials Mistakes observed iclude the couty that prited slightly differet iformatio about the target age group o differet materials as there had bee o fial proof-reader. Comprehesive Cervical Cacer Prevetio ad Cotrol Some coutries promote a dual message for their populatios: Girls, get vacciated ow to protect your future! Mothers, get screeed to protect your health today! Whe promotig screeig, it is importat that screeig services are available. Adolescet health itegratio I oe souther Africa coutry, health workers distribute a Me, My Body, My Life magazie to all grade-4 studets while HPV vaccie is beig admiistered as part of the school health programme. Boys ad girls receive the magazie so that boys also beefit from the HPV vacciatio sessio. Studets ca read a rage of topics icludig puberty, immuizatio, bullyig, exercise, resistig alcohol ad drugs, ad the aswer questios, do activities, ad write joural-style etries about the topics. There are refereces to helplies ad the importace of talkig to trusted adults if they have cocers or questios. Cosiderig traslatio ad cosistecy Oe laguage Oe Pacific coutry reports that though populatios speak multiple laguages, it elected to maitai all HPV vaccie materials i Eglish which is atioally uderstood so as to elimiate cofusio about the messages. Fudig ad sustaiability Late release of fuds: Oe coutry prepared ad pre-tested high-quality materials i several laguages. However, due to the late release of fuds, the coutry had to prit ad distribute the materials may weeks after HPV vacciatio bega. We had to covice people at the same time we were tryig to vacciate 26

35 part II: HPV Vaccie them, said oe health leader. This caused udue cocers i the commuity ad shortterm problems for the programme. Sustaiig fudig Oe high-icome coutry reports paretal difficulties to fid the latest iformatio, due to the reductio i the commuicatio budget i the years followig the HPV vaccie s itroductio. There is a ew cohort of parets ad girls every year, said oe cervical cacer expert from the coutry, ad they eed to have access to clear ad updated iformatio. The lesso: esure a sustaied commuicatio budget. Icludig commuicatio i procuremet: Some middle-icome coutries report the egotiatios for vaccie procuremet esure the maufacturers iclude fudig for the commuicatio strategy. Me My body My life A magazie for Grade 4 learers WATER 1 27

36 HPV Vaccie Commuicatio: Special cosideratios for a uique vaccie 2016 update Gettig started: what to cosider ad what to do Experiece from other coutries suggests the several broader lessos for HPV vaccie commuicatio. Start early While ot uique to HPV vaccie, it is best to start commuicatio plaig early. Give the distictive attributes of HPV vaccie ad the potetial for commuity cocers, plaig several moths i advace of itroductio allows for the research, situatio aalysis ad pre-testig eeded to successfully itroduce this ew vaccie. Startig early also meas havig budgets approved early which traslates ito materials that are ready o time. Plaig early meas budgets ca be approved early esurig that implemetatio ca take place o time. A review of coutry experieces showed that implemetatio ra more smoothly whe social mobilizatio activities bega at least a moth before itroductio. 8 Build a cross-sectoral team HPV vaccie may be delivered through the existig immuizatio structures, but the health implicatios ad beefits cut across may sectors ad programmes. The programme plaig team ad the commuicatio team should itegrate relevat sectors early. Each coutry should map all relevat sectors. These ca iclude: the cervical cacer team, wome s health practitioers, icludig gyaecologists ad obstetricias, adolescet health practitioers icludig paediatricias, the Miistry of Educatio, groups such as wome s, girls, youth ad educatio associatios, service clubs - such as Lios ad Rotary which are ofte ivolved i immuizatio, religious orgaizatios ad associatios, or relevat couterparts i UN agecies such as WHO, UNICEF, ad UNFPA, ad iteratioal NGOs such a PATH ad other local parters. Workig across sectors ad programmes expads huma ad fiacial resources, taps existig kowledge, promotes ew ideas ad builds large etworks that ca reach people at all levels of society with cosistet messagig. Buildig a strog multi-sectoral partership is also a opportuity to esure o group feels its territory is beig threateed. At the same time, this approach requires more time to harmoize agedas ad build cosesus aroud messages ad activities. 8. LSHTM/PATH HPV Vaccie Lessos Leart & Recommedatios,

37 part II: HPV Vaccie There will be cocers Coutry experiece shows that some commuities ad health workers will have cocers about HPV vaccie. Coutries ca aticipate cocers ad rumours about: The source ad relative ewess of the HPV vaccie The vaccie may be perceived to be a ew experimetal product from wealthy coutries that is beig tested i poorer coutries. The words demostratio project ca also trigger suspicio that this is a experimetal vaccie. Some coutries udertakig Gavi-supported demos have called it a learig process or foud other ways to describe why just a few districts are beig targeted. Commuities ad health workers may wat more iformatio about the safety, efficacy, side effects, log-term effects ad experieces with HPV vaccie i other coutries. The targetig of youg girls Some people may woder if HPV vaccie will have a impact o girls fertility. They may take the idea further ad suggest there is a plot to sterilize girls. Others may woder if vacciatio will ecourage girls to become promiscuous, despite studies that demostrate otherwise. 9 Recogizig that HPV is a STI, some may misuderstad the eed to vacciate girls early, protest that their girls are ot yet sexually active ad believe that vacciatio is ot yet ecessary. People may woder why boys are ot beig vacciated too as is happeig i a few coutries. Wome may woder why older adolescets ad adult wome are ot beig vacciated. The cost of the vaccie to the atioal health budget I coutries payig for the vaccie with atioal fuds, professioal health associatios may woder why HPV vaccie is beig itroduced give its expese ad fear this may impact decisios to fud other vaccies or services such as cervical cacer screeig ad treatmet. Advocacy with groups that may have specific cocers Some ifluetial groups such as health professioal associatios, private schools, paretteacher associatios, religious associatios, other civil society actors - may have specific cocers about HPV vaccie which, if uaddressed, ca lead to serious cosequeces. They ca iterrupt HPV vaccie delivery with oe widely publicized ews release. These groups may mistakely focus o girls fertility or sexuality. They may questio whether the vaccie meets stadard religious criteria 9. Several studies show that HPV vaccie has o correlatio with promiscuity or with eurological disease. For example, a study of more tha 260,000 girls, published i 2014 foud that cocers over icreased promiscuity followig HPV vacciatio are uwarrated, with strog evidece that HPV vacciatio has o sigificat effect o cliical idicators (STIs, pregacy) of sexual behaviour. See: Smith, L et al. Effect of huma HPV vacciatio o cliical idicators of sexual behaviour amog adolescet girls: the Otario Grade 8 HPV Vaccie Cohort Study. CMAJ, 8 December A 2014 Scadiavia study showed o correlatio betwee HPV vacciatio ad multiple sclerosis. See: Nikolai Madrid Scheller et. al. Quadrivalet HPV Vacciatio ad Risk of Multiple Sclerosis ad Other Demyeliatig Diseases of the Cetral Nervous System. JAMA. 2015;313(1): doi: /jama For more o HPV vaccie s safety profile, see this report from the Global Advisory Committee o Vaccie Safety: committee/topics/hpv/dec_2013 ad this WHO 2014 positio paper: 29

38 HPV Vaccie Commuicatio: Special cosideratios for a uique vaccie 2016 update (e.g. halal). Oe coutry experieced high resistace from several health associatios, which publicly criticized the itroductio of HPV vaccie as beig too expesive. Their resistace sparked more questios ad cocers from health workers ad parets, ad cotributed to low coverage which persisted for several years. Tip»» It is importat to aticipate cocers, idetify ad egage with ifluetial groups early. Discuss ad address their cocers ad brig them ito a wider coalitio so that they ot oly tolerate HPV vaccie, but proactively support it. Uderstad ad pla for the hard-to-reach girls Hard-to-reach girls icludig those who are ot i school may also be at higher risk of HPV ifectio ad developig cervical cacer. These may iclude girls: who have low socioecoomic status, who remai home to help with child-rearig or the family busiess, livig i remote regios, from miority cultures icludig omadic groups, with disabilities, who move frequetly with their families (e.g. migrat or seasoal workers), who atted school oly part time, who have left home ad live i dese, urba areas, or who are HIV-positive. Some coutries report it is very difficult to eumerate, locate, mobilize ad immuize these girls. Oe coutry reported very high coverage of girls i school (more tha 95% admiistrative coverage) but much lower for girls out-of-school (less tha 65%). While challegig, a commuicatio pla should attempt to reach these girls through chaels they trust whether through household ad commuity outreach, popular social media, messages through peer etworks, adolescet friedly health services, housig, employmet settigs or popular youth veues. The messages should stress the risks of cervical cacer, beefits of the vaccie, the two-dose schedule ad the fact the govermet is offerig the vaccie free of charge. The first year will have some challeges Eve with good preparatio, challeges are likely to emerge durig the first year of HPV vaccie itroductio. These may relate to service delivery but ca iclude rumours ad misuderstadig about the vaccie. Good commuicatio plaig ca aticipate this ad provide audieces the iformatio they eed to uderstad ad support the programme. 30

39 part II: HPV Vaccie Kowledge will likely be low Experiece ad available research to date show that kowledge about cervical cacer, HPV ad HPV vaccie is poor particularly i low- ad middle-icome coutries. A recet survey i rural Idia of more tha 1000 wome, of whom 85% were literate, revealed that oe had heard of HPV or its side-effects. 10 Formative research i Lao People s Democratic Republic foud low kowledge amogst mothers ad commuity leaders about the correlatio betwee HPV ad cervical cacer. 11 A survey of 449 ethically diverse wome i Malaysia foud that kowledge of HPV, HPV vaccie, cervical cacer risk factors ad cervical screeig was extremely poor. 12 I a survey of 289 wome attedig medical cliics i urba Botswaa more tha half said they did ot kow what causes cervical cacer, ad almost oe attributed it to HPV ifectio. 13 Formative research i Ugada foud recogitio of cacer as a serious health problem, ad awareess of a lik betwee cervical cacer ad sexual activity, but very little kowledge about HPV. 14 High coverage ca be achieved Despite poor kowledge, demad for HPV vaccie has geerally bee good i may low-, medium- ad high-icome settigs. I Rwada, for example, wome were demadig the HPV vaccie for themselves as well as for their daughters. I Malaysia, a catch up HPV vaccie programme was added to exted vacciatio to 18-year-old girls. May coutries achieved good coverage. Both Rwada ad Malaysia reported coverage of more tha 85% of the i-school populatio. A coverage survey of the Uited Republic of Tazaia s ad Seegal s demostratio programmes revealed coverage well above 90%. The demostratio project i Ugada resulted i 85% coverage i the school-based programme. I Eglad, more tha 84% of year olds were fully vacciated from Both Australia (2014) ad Caada (2013) report that about three-quarters of the target populatio received all doses. 10. Sabeea S., et al. Kowledge, Attitude ad Practice about HPV Ifectio ad its Health Effects amog Rural Wome i Karataka, South Idia. Asia Pacific Joural of Cacer Prevetio. 16(12), WHO WPRO with the Lao PDR Uiversity of Health Sciece, Cervical Cacer, Immuizatio, HPV ad HPV Vaccie; A Rapid Kowledge, Attitude ad Practice Assessmet i Lao PDR; September 2013, upublished. 12. Li Pig Wog. Kowledge ad Attitudes About HPV Ifectio, HPV Vacciatio, ad Cervical Cacer Amog Rural Southeast Asia Wome, Iteratioal Joural of Behavioral Medicie; Jue 2011, Volume 18, Issue 2, pp Migo, Alicea M. et al. Cervical Cacer Awareess ad Screeig i Botswaa, Iteratioal Joural of Gyecological Cacer: May Volume 22 - Issue 4 - p PATH ad Child Health ad Developmet Cetre (CHDC). Shapig a Strategy to Itroduce HPV Vaccies i Ugada: Formative Research Results from the HPV Vaccies: Evidece for Impact Project. Seattle: PATH;

40 HPV Vaccie Commuicatio: Special cosideratios for a uique vaccie 2016 update HPV vaccie i commuicatio plaig Multi-year commuicatio pla ad budget The ultimate goal of HPV vaccie itroductio is to itegrate it as a log-term cervical cacer prevetio tool, whereby HPV vacciatio of target-age groups becomes a social orm. Coutries may wat to reduce the HPV vaccie commuicatio budget after the first year. However, each year brigs a ew cohort of target-age girls ad their parets, ad they may be learig about HPV vaccie for the first time. New health workers ad teachers will joi the system ad be traied or orieted. A large-scale mass-media campaig may ot be ecessary each year, but commuicatio to remid audieces about the reasos, dates ad schedule of the HPV vaccie programme; opportuities to ask questios (e.g. radio call-i programmes, school ad commuity meetigs); iformative literature; moitorig ad respodig to rumours ad cocers will be ecessary for some time util HPV vaccie becomes routie withi the health system. Situatio aalysis ad formative research Depedig o the coutry, the situatio aalysis may require formative research for a HPV vaccie commuicatio pla. Research ad experiece to date i may coutries shows a similar set of commuicatiorelated issues, as captured i the table o page 24. Withi commuities this icludes a relatively low level of kowledge about cervical cacer, HPV ad HPV vaccie; a fear of cacer; ad a desire to protect childre from disease. Some caregivers, health workers ad commuity leaders will be cocered about targetig adolescet girls with a vaccie for a sexually trasmitted ifectio. Some will worry about side effects ad safety. Commuities that traditioally do ot support vacciatio will possibly reject the HPV vaccie. Other cosideratios are summarized i the table o page 24. A situatio aalysis for the commuicatio pla should cosider these issues, together with: coutry experiece itroducig other ew vaccies or public health itervetios, ay previous KAP studies o immuizatio ad health, adolescet health iformatio, school erolmet, sociocultural studies, demographic ad health surveys, multiple idicator cluster surveys, mass media aalyses ad other sources. Aalysig these sources should provide a lot of iformatio that will iform the commuicatio strategy s situatio aalysis. New research, which ca rage from a small series of focus group discussios ad key iformat iterviews to more comprehesive surveys, ca add critical iformatio. Some coutries with high levels of routie immuizatio coverage, for example, have challeges itroducig HPV vaccie. Research may reveal surprisig results ad fidigs about the target populatios ad idicate other areas that require improved commuicatio (e.g. o kowledge about cervical cacer ad screeig, or the roles that fathers play i decisios to immuize girls). 32

41 part II: HPV Vaccie Sample research questios for health workers, commuity members: About cervical cacer What is cervical cacer? What causes cervical cacer? Who is at risk of cervical cacer? How ca it be preveted? What is it called i the local laguage? About HPV What is HPV? What problems does it cause? How is it trasmitted? How ca it be preveted? About HPV vaccie What is HPV vaccie? How may doses are required? At what age? Would you accept it for you/your daughter/i your commuity? Why or why ot? About immuizatio What do you thik of vaccies (positive/egative)? Why? Are your childre/is your commuity fully vacciated? Why/Why ot? Who makes decisios about vacciatio i your family? About source of iformatio Who do you trust to give you health iformatio? How do you prefer to get health iformatio (e.g. face-to-face, ews media, SMS, social media, outdoor media other)? What sources make you ucomfortable or suspicious? Why? 33

42 HPV Vaccie Commuicatio: Special cosideratios for a uique vaccie 2016 update Formative research, icludig focus group discussios ad key iformat iterviews, is also part of the commuicatio egagemet process ad ca sigal geuie care about addressig the views of target groups. It ca also help to pipoit laguage ad termiology for sometimes sesitive areas such as sexual behaviour ad aatomy, or for colloquial laguage, as well as ew iformatio chaels used by target-age girls (e.g. use of specific social media). If a coutry would like to coduct formative research i advace of HPV vaccie itroductio, parters icludig WHO ad PATH ca provide guidace. Such research should be coducted moths i advace of the plaed itroductio so that the results ca iform the commuicatio strategy. It should be desiged to iform a comprehesive cervical cacer cotrol strategy, icludig educatio, HPV vaccie itroductio, screeig ad treatmet. 15 The issue of coset Coset, by defiitio, must be iformed, uderstood ad volutary ad the perso givig it must have the capacity to make the decisio. Coset procedures for immuizatio will vary by coutry, ad ca iclude formal, writte coset (e.g. the caregiver sigs a form); verbal coset; ad implied coset (e.g. attedace ad agreemet at a commuity iformatio meetig). Coset ca be opt-i whereby caregivers proactively agree to their child beig immuized, or opt-out whereby vacciatio proceeds uless the caregiver idicates otherwise. For HPV vaccie, coutries have foud that the itroductio of ew coset procedures formal writte opt-i procedures, for example, whe coset for immuizatio has traditioally bee verbal opt-out has led to suspicio that the HPV vaccie is experimetal or risky. I geeral, coutries have had better HPV vaccie immuizatio outcomes whe coset is optout; ad several coutries have switched to a opt-out approach after oe year of tryig a opt-i approach. I additio, coutries have geerally foud that legthy coset procedures resulted i some girls missig the opportuity to be vacciated. Fially, coutries report that private schools geerally required some form of writte caregiver coset (opt-i or opt out). I ay case, both coset letters ad iformatio sessios to parets are a good opportuity to commuicate with parets about related messages. For example, o the importace of cervical cacer screeig i wome, cervical cacer risk factors such as smokig, or additioal services available to adolescets. WHO s Cosideratios regardig coset i vacciatig childre ad adolescets betwee 6 ad 17 years old provides additioal guidace to coutries o the issue of coset ( ly/vacciecoset); ad the PATH/LSHTM HPV Vaccie lessos leart & recommedatios also provides data o HPV vaccie coset i coutries ( 15. PATH. Coductig Formative Research for HPV Vacciatio Program Plaig: Practical Experiece from PATH. Seattle: PATH; Available at 34

43 part II: HPV Vaccie HPV vaccie audieces Each of the followig audieces are importat. Their uderstadig, egagemet ad support ca make the differece betwee success ad failure of the HPV vaccie effort. Namig these specific audieces does ot exclude others. Coutries should aalyse who else must be reached whether it be commuity leaders, traditioal healers, civil society, popular artists or others. Target-age girls Girls are a core audiece. They should demad the vaccie ad promote it to their family ad peers. Girls eed basic iformatio: They eed to kow why a health worker will give them a HPV vaccie ijectio, how may doses they require, whe ad where they will receive them. Youger girls may ot eed to kow all of the details. I fact, girls surveyed geerally care most about oe issue: will the ijectio hurt? All girls should be told the ormal side effects of the ijectio ad kow whe side effects require a visit to a health cliic. Ideally, the girl should lear eough at the time of HPV vaccie ijectio to recall that whe she is older she should still go for cervical cacer screeig. Girls are a chael of iformatio to their frieds, parets, sisters ad auts they ca brig home iformatio that others ca read ad discuss, or talk about it with their sisters or frieds. This icludes iformatio for mothers/sisters/auts to be screeed for cervical cacer. Where coset is required, girls should be iformed about how the coset process works. As already metioed, hard-to-reach girls require special cosideratio. Trusted chaels of iformatio for girls: Caregivers Teachers Exteded family, icludig auts, gradparets, brothers ad sisters Commuity leaders Religious leaders Media, icludig social media Caregivers i the immediate ad exteded family Reachig caregivers ca be difficult. I Rwada, for example, fewer tha 20% of girls surveyed cited their parets as their source of iformatio for HPV vaccie. I Malaysia, fewer tha 5% cited parets as a source. Parets ad caregivers should feel iformed so they ca discuss ad promote HPV vacciatio with their daughters, give coset, ad kow where to ask should they have questios. Caregivers may have cocers about their daughter s health, the potetial for promiscuity, perceived impacts o mestruatio ad fertility, vaccie safety, side effects ad logterm effects. Some caregivers will have access to the Iteret ad read egative ews reports ad rumours i the absece of correct iformatio ad egagemet they ca pass false iformatio through the commuity. 35

44 HPV Vaccie Commuicatio: Special cosideratios for a uique vaccie 2016 update May caregivers will believe their daughter is too youg to seriously discuss or give coset for HPV vacciatio. I may coutries, the father will be resposible for givig formal coset ad eeds to be reached with iformatio he trusts. Mothers, gradmothers or auts i the exteded family may be a key source of iformatio. They will also beefit from iformatio about cervical cacer screeig ad treatmet. Caregivers may seek multiple sources of iformatio about HPV vaccie. If they hear about it through school, for example, they may also seek advice from their health worker, frieds or trusted commuity leaders. I coutries with cervical cacer screeig, reachig out to mothers, auts ad older sisters is also a opportuity to reach eligible wome with messages about cervical cacer screeig. Trusted chaels of iformatio for caregivers: Other family members Peers/frieds Teachers ad headmasters Commuity leaders Religious leaders Local ad atioal officials Scietific experts Local ad mass media (the actual publicatio/programme will vary by commuity) Health workers icludig commuity health workers Health workers are a essetial audiece. Their active support ad promotio of HPV vaccie ca have a impact o demad ad coverage. Health-worker iterpersoal commuicatio skills with girls, caregivers, teachers ad commuity leaders are a key to success. Health workers may have questios about the HPV vaccie, or about the biological liks betwee HPV, the vaccie ad cervical cacer. They may also wat to lear about other STIs or other types of cacer. Health workers may also have access to the Iteret ad will search for more iformatio o these issues. They too could fid false iformatio ad rumours. Health workers should: udergo traiig icludig iterpersoal commuicatio (IPC) traiig, udergo traiig to idetify ad address the special eeds of adolescets beyod vacciatio, ad have access to materials they ca lear from, ad they ca use to teach others such as a leaflet, a Frequetly Asked Questios list, ad a poster with images ad simple phrases. Trusted chaels of iformatio for health workers: Their family ad peers District ad atioal supervisors Experts Gyaecologists, ocologists, researchers, academics Health professios associatios Some iformatio o the Iteret Iteratioal authorities, e.g. WHO. 36

45 part II: HPV Vaccie Headmasters ad teachers If HPV vaccie delivery is school-based, headmasters ad teachers will be o the frot lies of the programme ad ca be a lichpi to success. They are frequetly a source of iformatio cited most by girls. They may give permissio to health teams to vacciate i schools ad use valuable class time for vacciatio sessios. They may also actively participate i traiig or orietatios, register Tip Some coutries report that paretteacher associatios have bee oe of the most importat audieces to esure acceptability. girls, educate girls about the vaccie, remid them of the schedule, ad arrage coset with parets. They ca also help with the sessios i other ways, for example by recordig attedace, updatig ad maitaiig vacciatio cards at school ad referrig girls who missed a sessio to the earest health facility. They may also coordiate iformatio with health workers ad with parets through paret-teacher associatios. Headmasters ad teachers should receive tailored traiig o HPV vaccie separate from health workers (ad i collaboratio with the Miistry of Educatio ad ay private school associatios) coverig key messages ad their roles ad resposibilities. They should have formal opportuities to coordiate with health workers (e.g. joit meetigs). They should have access to IEC materials that both explai HPV vaccie, ad egage ad mobilize caregivers ad daughters. Trusted chaels of iformatio for headmasters ad teachers Family ad peers Miistry of Educatio Health workers Health ad sciece experts Local ad atioal officials Commuity leaders Mass media (will vary depedig o the source) Tip Carefully map out ad prioritize the associatios ad civil society orgaizatios most relevat i your coutry. Oe coutry, for example, was surprised whe its huma rights commissio publicly questioed the HPV vaccie shortly before the lauch. Professioal, cultural ad religious associatios Relevat associatios should be idetified, egaged i advocacy ad icluded as a direct parter or withi the broader coalitio of supporters. Whe they are cofidet i the programme, their leaders ca become champios ad advocate publicly for caretakers to have their girls vacciated. These iclude: Professioal medical or ursig associatios. Recommedatios from health care providers are a factor i people s decisio to have their daughters vacciated. Several coutries co-brad their HPV vaccie programmes with the associatio of gyaecologists or obstetricias; paediatricias ad cacer specialists are also importat. Trusted health practitioers ca be ivolved i iterviews ad public service aoucemets promotig HPV vaccie. 37

46 HPV Vaccie Commuicatio: Special cosideratios for a uique vaccie 2016 update Religious ad traditioal leaders associatios. I several coutries, buy-i from religious leaders has bee critical to the HPV vaccie programme. Messages set through churches ad mosques are ofte cited as a importat source of iformatio ad correlate with vaccie uptake. Wome s groups ad associatios. Adolescet health advocates. Youth groups ad adolescet support services. Trusted chaels of iformatio They will vary from group to group. As associatios are idetified, map out the chaels of iformatio that they will trust most. Each group may eed differet kids of evidece-based iformatio such as the burde of cervical cacer i the coutry, the costs of treatmet ad the cost-beefit of HPV vacciatio. They may also wat more evidece ad iformatio from other coutries. Media The media ca be champios for HPV vaccie through accurate reportig ad promiet placemet of stories. However, if there is a iformatio gap, they ca also be quick to report misiformatio they might fid from other sources. They may, for example, be targeted by ativacciatio groups who will lead them to false iformatio. Media will vary from coutry to coutry ad have greater or lesser trust i govermet programmes. The media eed: A orietatio, with trusted experts, o HPV vaccie well before its itroductio. A ogoig relatioship with the EPI programme, icludig people they ca call with questios. Briefig materials icludig a ews release, fact sheet, FAQs. Timely resposes to their questios that meet their publicatio deadlies. Access to a spokesperso at all times, icludig i times of crisis. Trusted chaels of iformatio for media They will deped o the coutry ad the type of media (e.g. state-owed or private sector) but geerally media value the followig sources for ews stories: Seior political leaders Idepedet experts, e.g. gyaecologists, ocologists, researchers, academics Iteratioal orgaizatios such as WHO or UNICEF Seior leaders of associatios icludig health or religious associatios Commuity leaders ad members Media also value sources who will give the other side of the story this icludes sources who may oppose HPV vaccie. 38

47 Itroductio Commuity collaboratio success Rwada s HPV vaccie commuicatio materials show parets with their daughters, ad messages are i Kiyarwada, Rwada s official laguage. HPV vaccie programmes i Rwada, Ugada ad Peru; each show the importace of ivolvig teachers ad health workers i the commuicatio process. I Rwada, every district health cetre hosted joit meetigs with health workers, commuity leaders, headmasters ad teachers before each roud of vacciatio. Educators leared about HPV vaccie ad their roles i esurig their studets were reached i the classroom. Rwada girls surveyed cited school ad health workers as two of the top three sources of iformatio about HPV vaccie (radio raked first). a Ugada s HPV vaccie demostratio project foud that close collaboratio betwee the commuity, teachers ad health workers was a key factor i higher coverage. Joit plaig meetigs i advace of vacciatios were essetial to the success of the vacciatio programme. The participatio of teachers, health workers, ad commuity leaders i the meetigs provided a opportuity to coordiate work plas, time lies, resources, itervetios, moitorig ad reportig. This also promoted close collaboratio betwee the departmets of health ad educatio ad ecouraged a cooperative eviromet durig vacciatio sessios. b This kid of collaboratio was credited with some of the success i a demostratio project i Peru: Feedback from parets ad their daughters idicated that although may iitially reacted to the ew vaccie with scepticism ad doubt, these doubts were overcome by educatioal efforts by teachers ad health workers, as well as iformatio parets sought idepedetly. I Peru there was also evidece that where teachers were ot egaged, the programme was affected. I places where teachers were ot ivolved i or supportive of vacciatio, there was also distrust or lack of egagemet amog parets. For example, oe health worker described how teachers at oe school failed to actively coordiate educatioal commuity meetigs, which meat that o parets showed up. c a. Results of a post-itroductio evaluatio i Rwada, October b. Ugada Miistry of Health ad PATH. HPV Vacciatio i Africa: Lessos Leared from a Pilot Program i Ugada, c. Peru Miistry of Health, Istituto de Ivestigacio Nutricioal, PATH. HPV Vacciatio i Lati America: Lessos leared from a pilot program i Peru,

48 HPV Vaccie Commuicatio: Special cosideratios for a uique vaccie 2016 update Effective messages There is o magic formula for HPV vaccie messagig, ad it will vary betwee ad withi coutries. Kowledge of the coutry populatios, a thorough situatio aalysis ad pretestig will help to guide messages. For HPV vaccie, key messages iclude: A cacer vaccie I geeral, coutries refer to the HPV vaccie as a cacer vaccie, rather tha a vaccie agaist a sexually trasmitted ifectio. This is sesible for may reasos. For oe, people will kow about ad fear cacer more tha HPV (which they may have ever heard about). If the perceived beefit is to prevet a cacer, the vaccie will pique more iterest ad demad. Secodly, the termiology is accurate as the mai purpose of the vaccie is to prevet cervical cacer. Third, referece to a cacer vaccie may dimiish cocers that the vaccie is liked to icreased sexual activity or fertility. Where boys are also beig vacciated, messages ca iclude the beefits of protectio agaist aal, peile ad cacers of the mouth ad throat (though boys may respod more to the threat of geital warts which the 4-valet HPV vaccie also protects agaist). Oe cautio The biology of HPV, its sexually-related route of trasmissio ad lik to cervical cacer is a ievitable message that must be explaied. This is importat as there is ofte a mistake belief that my daughter is too youg to be havig sex ad she therefore should ot be vacciated. All caregivers ad health workers eed to uderstad that the vaccie will be most effective if admiistered before exposure to HPV, before sexual activity begis. It is a key secodary message that ca be delivered by a trusted, well-kow atioal health practitioer to health workers, teachers, caregivers ad commuity leaders. This message requires varyig levels of sophisticatio depedig o the audiece. The explaatio ca be factual ad straightforward ad should stress: that HPV is very commo, the majority of the populatio will become ifected with HPV, some of these ifectios will develop ito cervical cacer, the immue reactio to two vaccie doses is much better i girls 9 to 13 years of age tha i older girls, vacciatig girls today will protect them from a virus that could cause cacer i the future. Coutries will kow the most culturally appropriate way to covey the message. Some coutries, for example, stress that umarried girls should be protected, uderstood as girls who are ot yet sexually active. Remember: Girls who are 15 years or older whe they receive the first dose, or girls who are immuocompromised should receive three doses (at 0, 1 2 ad 6 moths). 40

49 part II: HPV Vaccie GOVERNMENT ENDORSEMENT It should be clear that the govermet edorses the vaccie, through public statemets (lauch, iterviews, speeches) ad o the materials (through texts ad logos). TWO DOSES I order to cofer maximum protectio, WHO recommeds that HPV vaccie be delivered as a two-dose schedule for girls uder fiftee years of age, with a iterval of 6 moths betwee the two doses that ca be exteded to a moth iterval. 16 As drop-out is a risk, stress the schedule i commuicatios to girls, caregivers, health workers, teachers, commuity leaders ad other relevat audieces. WHERE AND WHEN Messages must iclude iformatio about whe ad where the vaccie will be available. Lack of awareess about where ad whe vacciatio will take place is associated with o-vacciatio. EVIDENCE People have may questios about HPV vaccie. Evidece from research ad coutry experiece ca help to egage ad covice people. Differet kids of evidece will appeal to differet groups. Families may eed basic iformatio about cervical cacer ad vaccie safety, whereas more seior leaders ad decisio-makers may eed to kow more about the cost-beefit or wat more detailed scietific iformatio. Provide basic evidece about the cervical cacer icidece i the coutry ad why it is importat. For example: Cervical cacer is oe of most commo cacers affectig wome. It is the (x) highest cause of cacer i wome i our coutry. Cervical cacer is oe of the deadliest cacers affectig wome. It is a deadly disease that causes (x) umber of deaths each year. Cervical cacer ca be preveted through vacciatio, cervical screeig ad treatmet. We are offerig a vaccie, free of charge, that ca protect girls agaist most cervical cacer. Evidece about the cost-effectiveess of itroducig the vaccie is also importat ad covices health practitioers about the merits of the vaccie as the most cost-effective way to prevet cervical cacer. Evidece about HPV prevalece. People may ot see cervical cacer as much of a problem. A gyaecologist may oly see a hadful of cervical cacer cases durig the course of her career, ad to her, the HPV vaccie may ot seem like a priority. 16. For the latest WHO recommedatios o the routie immuizatio schedule, please check the WHO web site: immuizatio/policy/immuizatio_tables/e/. 41

50 HPV Vaccie Commuicatio: Special cosideratios for a uique vaccie 2016 update Evidece about vaccie safety: the HPV vaccie is approved ad licesed by the atioal authorities; it is recommeded by WHO; multiple studies show the vaccie is safe; additioal messages that the vaccie is halal for example may also be helpful. Evidece from other coutries: People i may coutries really wat to kow what is happeig with HPV vaccie i other coutries. Therefore, provide iformatio about the umber of coutries usig HPV vaccie (ad judge whether populatios will be more motivated by the fact it is beig used i higher-icome coutries, i eighbourig culturally similar coutries or both), the safety record i other coutries ad studies showig the safety ad beefits of HPV vaccie from coutries which itroduced the vaccie several years ago. 17 Testimoials People like to see ad hear other people s experiece. A short testimoial from a mother who lost a sister to cervical cacer, for example, about why she chose to protect her daughter helps other mothers relate to someoe advocatig for HPV vaccie. A testimoial from a famous actress who has vacciated her daughters could also be effective. Trusted atioal leaders, gyaecologists or other experts could also offer effective testimoials. These could be used i pamphlets, i televisio or radio broadcasts. Side effects A HPV vaccie ijectio, like almost ay itramuscular ijectio, will have some mild side effects. Girls, caregivers, health workers ad teachers should be aware of the commo side effects so they kow that these are ormal. Jouralists should be briefed o these as well, to reduce the risk of reportig icorrectly o AEFI issues. These groups also eed to kow whe side effects are serious eough for girls to see a health practitioer. Depedig o the settig, this kid of iformatio ca be told to girls verbally but should be available i a questio-ad-aswer documet for health staff ad teachers. I Malaysia, for example, every coset form set home to parets icluded a AEFI checklist so that parets could report eve mild adverse effects to the health system. INTEGRATED WITH CERVICAL CANCER SCREENING Coutries with cervical cacer screeig ca produce itegrated cervical cacer prevetio messages. Messages ca ecourage both girls ad their mothers to take actio to prevet cervical cacer. A example would be a campaig that reads, Girls get immuized! Wome get screeed! WHO has prepared vaccie iformatio sheets with the observed rates of vaccie reactios, icludig for HPV vaccie. They are available here:

51 part II: HPV Vaccie Itegrated with adolescet health Coutries itegratig adolescet health services with HPV vaccie such as dewormig tablets or other vaccies should esure HPV vaccie materials iclude messages about these additioal itervetios. Coutries with adolescet health programmes atioally, i schools, health cliics, youth cetres or through associatios should cosider itegratig HPV vaccie messagig ito adolescet health iformatio materials. They ca also use the HPV vacciatio ad messagig to stregthe referrals to other itervetios for adolescets For more o itegratig adolescet health itervetios with HPV vaccie, see WHO s Optios for likig health itervetios for adolescets with HPV vacciatio, WHO, 2014, 43

52 part II: HPV Commuicatio: Vaccie HPV Vaccie Special cosideratios for a uique vaccie 2016 update Multicultural Malaysia, messages ad mixed media Malaysia had a host of factors to cosider whe it prepared its HPV vaccie commuicatio pla. Malaysia citizes iclude ethic Malays, Idias, Chiese ad other commuities who speak differet laguages ad use differet media i daily life. Some groups read the ewspaper more the head of public health commuicatio explais, while others watch more televisio, so we have to tailor materials to all of these groups i the differet laguages ad chael them i differet ways. Malaysia produced materials i four laguages ad esured the visual portrayal of differet ethicities. The Miistry of Health paid for media spots by strategically purchasig space o radio programmes, i ewspapers ad televisio shows preferred by differet groups. They also tailored more materials for girls icludig upbeat, fu desigs ad used social media sites like Twitter ad Facebook to egage girls ad aswer their questios. The Miistry also publishes HPV vaccie materials o its website, where they ca be dowloaded ad reprited. Malaysia HPV vaccie materials also pictorially show the pathway of HPV to the cervix ad where it causes cacer. Whe asked i a survey, about 7 i 10 rural girls correctly idetified sexual activity as the source of HPV. 44 I summary, Malaysia kew its populatio s cultures, laguages ad media prefereces very well, ad tailored material to differet groups. Malaysia also preseted factual iformatio about HPV ad cervical cacer so that the populatio had a basic uderstadig of how HPV was trasmitted ad why the vaccie should be give to girls before they were sexually active. Sice Malaysia itroduced HPV vaccie, cofidece i the programme has grow ad Malaysia reports high coverage, icreasig from 98 to 99.6% i the period.

53 part II: HPV Vaccie Materials ad chaels Coutries will kow which materials ad chaels work best for their populatios. I additio to the guidace offered i the first sectio of this documet, HPV vaccie-specific guidace icludes the followig: Keep materials clea ad simple Fewer words ad more images work best, particularly for lay audieces. Use every opportuity Messages ca be prited, for example, o the back of the HPV vaccie immuizatio card. The Miister of Health ca talk about HPV vaccie i speeches about materal ad child health. A short message ca be give i a cocert by a siger popular with adolescet girls. Thik through all opportuities to iclude HPV vaccie ad cervical cacer messages. Produce a log, stadard frequetly asked questios (FAQ) referece guide with every coceivable questio. Use this as the basis for shorter prited FAQs for differet audieces icludig health workers (for their traiig ad as a referece), jouralists, professioal associatios, etc. Use it also as the basis for talkig poits for speeches ad media iterviews. There is a stadard FAQ icluded at the ed of this guide. Girls just wat to have fu Thik of ways to reach girls with laguage ad materials they ca relate to ad have fu with. Materials that are colourful with moder desigs will attract girls attetio. What games or etertaiers are popular with girls? Ca they be itegrated ito the desigs? I coutries where text messagig ad access to smart phoes is more commo, there may be opportuities for quizzes ad games i collaboratio with the mobile phoe service provider. Hotlies Some coutries have set up phoe hotlies so that girls, parets ad other audieces ca call ad ask questios. This ca be a effective way for people to have a real coversatio with a expert about HPV vaccie. If a hotlie is established, cosider the resource implicatios it will require sufficiet umbers of kowledgeable operators to aswer questios over a defied period of time. A mix of chaels is importat icludig face-to-face commuicatio from trusted leaders: Whe asked how they heard about HPV vaccie, surveyed girls cite multiple sources of iformatio, icludig radio ad televisio, school teachers, health workers ad church or mosque aoucemets. A study from Viet Nam ad Ugada showed that parets were more likely to have girls immuized whe they had spoke to commuity ifluecers icludig health workers, family ad commuity leaders which had a greater impact tha oly receivig IEC materials. The 2015 PATH/LSHTM meta-review of experiece i 37 coutries also showed that face-to-face commuicatio was the most effective way of mobilizig commuities, especially those that were likely to refuse vacciatio. 45

54 HPV Vaccie Commuicatio: Special cosideratios for a uique vaccie 2016 update Hard-to-reach girls may be foud i both urba ad rural areas: whe plaig for hard-to-reach girls, cosider those i large, desely populated cities who may eed to be reached via televisio, peers ad their caregivers, as well as those i remote areas, omadic commuities or girls affected by humaitaria crises. The Iteret ad social media Use of these mediums will completely deped o the coutry settig. Where access to social media is high, coutries might cosider settig up a Facebook or Twitter accout devoted to adolescet health, icludig HPV vaccie. These are resource-itesive activities, however, ad require almost daily moitorig ad updates. This ca be cosidered where the social media eviromet is highly accessible. Coutries with good Iteret access should cosider dedicatig a web site to HPV vaccie (or to the vacciatio programme i geeral) where ayoe ca access evidece-based iformatio, materials ad FAQs. Provided it is updated o a regular basis (e.g. quarterly), this site ca be a reliable source of iformatio. Tip»» If materials are traslated, esure the traslatio is 100% accurate ad cosistet across all materials particularly about key iformatio icludig the target age group, ad where ad whe the vaccie is available. Traiig ad orietatio Give the importace of iterpersoal commuicatio for successful HPV vaccie programmig ad the potetial for rumours ad questios, esure close collaboratio with the traiig ad orietatio team to create the traiig ad orietatio packages. There will probably be oe opportuity to trai ad oriet health workers, teachers, commuity leaders, ad media; they will all eed to receive cosistet messages that have bee created ad tested by the commuicatio team. All of these audieces will wat to be equipped with simple messages that ca egage commuities, together with aswers to commo questios ad rumours. Use the opportuity to equip health workers i particular with basic iterpersoal commuicatio skills essetial for HPV ad all vaccie delivery. 46

55 part II: HPV Vaccie Crises There is a good chace the HPV vaccie programme will face rumours at the very least, ad could face more serious programmig issues if AEFIs occur ad are ot hadled rapidly ad effectively. Give the importace of this topic, a thorough explaatio of crisis commuicatio is provided o page

56 HPV Vaccie Commuicatio coclusio & Summary

57 Itroductio Coclusio Cervical cacer, caused by sexually trasmitted HPV, is the secod most commo cacer i wome worldwide ad results i about deaths each year. Due to poor access to screeig ad treatmet services, more tha 85% of deaths occur i wome livig i lowad middle-icome coutries. WHO recommeds HPV vacciatio together with cervical cacer screeig ad treatmet as the most effective way to dramatically reduce death ad illess caused by cervical cacer. The vaccie is beig itroduced i a icreasig umber of coutries, ad millios more girls could be fully immuized by the ed of this decade. As described i this guide, HPV vaccie is uique ad requires careful thought ad ivestmet i commuicatio. A successful HPV vaccie commuicatio pla requires teams to start early, to expect a few challeges, to adjust as ecessary ad to persist well beyod HPV vaccie itroductio so that HPV vacciatio becomes a regular, sustaiable ad socially expected cervical cacer prevetio itervetio. This will require a ivestmet of time ad moey. Experiece shows that where coutries achieve sustaied high coverage with HPV vaccie, cotiuous ivestmet i strategic commuicatio played a critical role. High coverage will reduce cervical cacer ad improve the health ad lives of girls ad wome for geeratios to come. 49

58 HPV Vaccie Commuicatio: Special cosideratios for a uique vaccie 2016 update Summary: plaig ad cosideratios for HPV vaccie Commuicatio is: A process People eed time to chage behaviours to lear, absorb ad cofirm iformatio, make a decisio to act o it ad ecourage others to do the same. About commuity egagemet It is a coversatio ad ot a lecture. About equity with plas to egage hard-to-reach populatios. A ivestmet Effective commuicatio activities will cost moey ad time. The retur o ivestmet is improved immuizatio coverage ad better health for girls ad wome. Imperfect Commuicatio ivolves huma beigs, ad we caot predict what people will thik or do i every situatio. HPV vaccie is differet Start early Early plaig ca lead to o-time implemetatio. Begi commuicatig with commuities about a moth before the vaccie is itroduced. Build a cross-sectoral team HPV vaccie itroductio ivolves immuizatio, educatio, cacer, sexual ad reproductive health, adolescet health, youth, professioal associatios ad other key members of civil society. Coduct a situatio aalysis icludig formative research if ecessary. It is importat to uderstad how differet audieces uderstad ad will respod to HPV vaccie. Pla for a multi-year effort It will take time for HPV vaccie to settle i ad be accepted as a part of a routie programme. There will be cocers HPV vaccie is ew i the coutry; it is targeted at adolescet girls; it may ot seem like a priority, ad there may be rumours about whether it is a trial, its safety ad about fertility. Govermet edorsemet is importat for a successful programme. Idetify ad egage all groups that may have cocers. Esure advocacy plas for them. Uderstad ad pla for hard-to-reach girls. Who ad where are these girls? I the future, they may have the least access to cervical cacer screeig eve whe it is available i the coutry. Iterpersoal commuicatio from trusted ifluecers ca have the most impact. Trai health workers ad teachers to commuicate effectively about HPV vaccie ad esure religious ad commuity leaders uderstad ad kow how to promote it. The first year will have some challeges It is a ew programme ad there will be bumps, but High coverage ca be achieved HPV vaccie will save lives. Commuicatio has bee key to high coverage i coutries with successful programmes. 50

59 coclusio ad summary 51

60 HPV Vaccie Commuicatio: Special cosideratios for a uique vaccie 2016 update What WHY? HOW / WHAT? 1. Commuicatio team Needs multisectoral support. Egagemet with commuities is a job for a team, ot oe perso. 2. Programme objectives Clear programme objectives set the stage for commuicatio plaig. They describe the target populatio, the target coverage, the strategy ad the timelie for completio. 3. Situatio aalysis 4. SMART Objectives 5. Target audieces Uderstadig your audieces will help to desig a strategic commuicatio pla that uses resources most effectively. Will help to prioritise activities ad develop the most effective commuicatio strategy. Will allow measuremet of outcomes. The more specific the target audiece, the more focussed the strategies ad activities. Differet audieces may be suspicious or have more questios about HPV vaccie. It is a ew vaccie for everyoe icludig health workers. Audieces who do ot uderstad HPV vaccie may derail the programme (e.g. media, religious orgaizatios). Educatio sector will likely be part of the delivery strategy ad therefore eeds to be icluded i the commuicatio strategy. Esure traiig, icludig IPC traiig for health workers; ad for headmasters ad teachers. Iclude commuicatio experts from the govermet sectors ivolved i educatio, cervical cacer prevetio ad cotrol, adolescet health, immuizatio ad other relevat parters. Agreed by the iter-coutry coordiatio team or other oversight body. Aalyse existig kowledge (about populatios ad health, icludig immuizatio). If ecessary, coduct formative research usig focus groups, key iformat iterviews ad ideally surveys to get a baselie regardig kowledge, attitudes, behaviours ad practices for cervical cacer, vacciatio, HPV ad HPV vaccie. Use the situatio aalysis to prioritize activities that will achieve the most relevat results. Target-age girls (i school, out-of-school, hardto-reach). Caretakers i immediate ad exteded family. Headmasters ad teachers. Health workers. Professioal (e.g. ob/gys/cacer), cultural (e.g. youth, wome s ad religious associatios). Media. 52

61 coclusio ad summary What WHY? HOW / WHAT? 6. Messages for each audiece Differet groups will eed ad respod to differet kids of iformatio, from simple messages to more complex ideas about cost-beefit. People wat evidece. Health workers will appreciate more i-depth iformatio. Health workers should provide iformatio about side-effects. Health professioal associatios may eed to be coviced about the cost-beefit. People may worry about safety because it is a ew vaccie. 7. Strategies, activities, ad chaels Differet audieces will respod to a mix of differet strategies ad activities. Advocacy activities iclude oeo-oe meetigs or briefigs with specific small groups. Social mobilizatio works with orgaizatios to egage commuities to take actio. Test your messages with audieces. Callig it a cacer vaccie has bee most effective. Govermet edorsemet is essetial. Esure messages iclude where ad whe to go for vacciatio. Cautio: people still eed to kow the way HPV is trasmitted, that the vaccie is required before sexual activity begis ad that it works best i girls aged Requires two doses for girls aged 9 13, 6 moths apart. Requires three doses for girls aged 15 or older, or those who are immuo-compromised (at 0, 2 ad 6 moths). Use evidece icludig:»» cervical cacer icidece ad deaths,»» HPV prevalece,»» cost-beefit of itroductio,»» vaccie safety, track record, ad»» evidece about use i other coutries. Provide testimoials that are attractive to caregivers ad girls. Be ope about commo side-effects ad what girls should do, whe they should seek medical help. Itegrate messages with comprehesive cervical cacer prevetio ad treatmet. Itegrate messages with adolescet health. Esure messages iclude a call to actio. Selectig sources ad chaels people trust is critical. May audieces will respod to the messages if delivered by differet trusted sources ad reiforced through a mix of chaels such as a trusted atioal leader, a popular radio programme ad the commuity health worker or midwife. 53

62 HPV Vaccie Commuicatio: Special cosideratios for a uique vaccie 2016 update What WHY? HOW / WHAT? 7. Strategies, activities, ad chaels (cotiued) 8. Materials Social ad behavioural chage commuicatio works more directly with commuities icludig health workers, commuity leaders ad caretaker so that HPV vaccie becomes a social orm. Trusted chaels of iformatio will vary betwee audieces. There are a rage of materials to create for differet audieces. They ca iclude: a advocacy presetatio with a lot of data ad evidece for decisiomakers, traiig materials for health workers ad teachers, facts sheets, FAQs, ews materials ad media kits, materials for the commuity icludig simple posters, leaflets, baers, radio aoucemets, drama scripts, cartoo books, text messages ad traiig materials. 9. Crisis commuicatio pla HPV vaccie is cosistetly subject to rumours about safety ad fertility. There is a chace that ay adverse evet associated i time ad place with HPV vaccie will be wrogly associated with the vaccie. Experiece i coutries shows people respod best to iterpersoal commuicatio from trusted commuity members icludig health workers ad teachers. Differet commuities may respod to differet types of sources ad chaels, such as their ow commuity leaders or local radio statios. As the mai target audiece is girls, package their messages i appealig way (fu SMS text messages, iteret or social media where available). Cosider strategies to reach urba girls, who are bombarded with may messages every day. Some coutries have successfully used telephoe hotlies to aswer commuity questios. Pre-test materials for appeal, relevace, comprehesio, acceptability, persuasio ad recall. Keep materials simple with the mai messages easy to read ad absorb. Use more images tha text for laypeople. Use every opportuity prit messages, for e.g. o the back of girls immuizatio cards if they take these home. Mutually reiforcig messages by trusted commuity leaders, teachers, health workers ad religious leaders ca have excellet results. Produce a comprehesive frequetly asked questios documet that you ca use respod to all questios. Update this as you hear more questios. Correctly traslate materials ito local laguages ad esure the traslatios are cosistet. Esure a physical ad electroic distributio pla. Pla for a crisis, i cosultatio with stakeholders, ad secure fudig. Iclude stadard operatig procedures i the pla. Protectig public health is paramout i a crisis. 54

63 coclusio ad summary What WHY? HOW / WHAT? 9. Crisis commuicatio pla (cotiued) There is a heighteed risk of adverse evets followig immuizatio durig a campaig because of the large umber of ijectios beig give i a short period of time. Target-age girls ca be proe to faitig. A badly hadled evet ca lead to the rapid spread of misiformatio ad have a log-term impact o your immuizatio programme. 10. Moitorig ad evaluatio pla Allows trackig of progress ad adjustmets durig the course of the programme. Provides evidece to demostrate the value of the ivestmet i commuicatio. A evaluatio ca help to improve the programme i future. 11. A work pla with budget Aalyse the situatio if a crisis occurs for geographic locatio, scale, potetial risk to huma health ad immuizatio programme. If ivestigatio is required, esure it occurs rapidly ad report the results. Commuicate quickly, trasparetly, ad regularly. Tell people what actios they should take. Liste to public cocers ad respod to them compassioately. Aouce whe the crisis is over. Aalyse the impact o the programme, ad adjustmet to make i the future. A baselie ca be established from the situatio aalysis. Set targets, milestoes ad idicators. Determie how to measure progress whether through mii surveys, i-process moitorig, postitroductio evaluatio, focus groups, atioal surveys or a combiatio. Itegrate some commuicatio moitorig with the larger HPV vaccie programme moitorig. Ay pla requires a detailed work pla. Assig tasks to specific idividuals ad give deadlies. Determie ad secure the budget. 12. Adjust the work pla as required Commuicatio is a cotiuous process ivolvig huma beigs. Use moitorig to determie what is workig ad what is ot. If a activity is ot workig as aticipated, stop or adjust it. Be alert to rumours or misiformatio ad act rapidly to correct. Cotiue to ivest i commuicatio for HPV vaccie for several years util it is fully ormalized i the atioal immuizatio programme. 55

64 HPV Vaccie Commuicatio Aex: Crisis commuicatio for hpv vaccie

65 Itroductio Crisis commuicatio for HPV vaccie This sectio offers a summary of crisis commuicatio. For more iformatio, cosult the followig resources which were used to develop this sectio:»» WHO Europea Regioal Office s 2013 guide: Vaccie Safety Evets: Maagig the Commuicatio Respose. A Guide for Miistry of Health EPI maagers ad Health Promotio Uits. 19»» A WHO e-learig course etitled Vaccie Safety Basics icludig a case study o how a potetial HPV vaccie crisis was averted i the Uited Kigdom. 20»» The Global Polio Eradicatio Iitiative s Issues Maagemet Guide, October A crisis i immuizatio icludig for HPV vaccie ca occur for several reasos. Examples iclude: Icreasig vaccie hesitacy amogst some groups due to complacecy or a lack of cofidece i vaccies ad vaccie maufacturers. A adverse evet followig immuizatio (AEFI): A coicidece a evet that is perceived to be liked e.g. a oset of a debilitatig disease occurrig ear the time of immuizatio. 19. URL: WHO EURO. 20. URL: URL: /documets/polioedgame/issues_maagemet_guide-coutries.pdf. 57

66 HPV Vaccie Commuicatio: Special cosideratios for a uique vaccie 2016 update This ca iclude mass psychogeic evets, where several girls become ill at the same time. This has occurred i a few coutries icludig Brazil ad Colombia. Such a case i Japa is described o page 64. A serious AEFI while rare ca be due to programme error or a reactio to the vaccie that leads to serious illess, ijury or death; ad possibly to a vaccie recall. Poor commuicatio about chages i immuizatio policy or schedules e.g. a itroductio of a ew vaccie icludig HPV vaccie, without ivolvig relevat stakeholders icludig paediatricias, gyaecologists or religious leaders. Evets icludig safety scares, rumours or chages i the HPV vacciatio programme i aother coutry, eve o a differet cotiet. Misiterpretatio of ew research reported i the media. Misiformatio from the Iteret that spreads i a commuity. Groups with their ow, possibly urelated ageda (e.g. political) spread rumours to destabilize a programme, or eve take violet actio agaist health workers. Tip»» The ormal risks of AEFI icludig swellig at the site of ijectio or fever must be commuicated by health workers to all caregivers ad girls before immuizatio to avoid misuderstadigs. Be prepared Create a crisis commuicatio pla for EPI as part of the EPI commuicatio pla, ad a specific pla for HPV vaccie. Whe a crisis happes, it is too late. The pla should iclude: 1. Sources to sca regularly for potetial crisis such as the media, the Iteret, AEFI reports, commuity leaders. 2. Cosultatio ad agreemet with key stakeholders (e.g. Miister, EPI maager, NITAG, AEFI committee, district level health authorities, educatio authorities, major parters). Be aliged with the procedures for a AEFI with regards to ivestigatio, vaccie maagemet, protectio of public health. 3. Terms of referece, members ad cotacts for a crisis commuicatio team. The team should iclude commuicatio ad techical experts. 4. Idetify ad secure a fudig source should plas eed to be implemeted. 58

67 crisis commuicatio for HPV vaccie 5. Stadard Operatig Procedures: a chai of commad with clear roles ad resposibilities for key players, trigger poits or thresholds of whe ad where to put plas ito actio (e.g. a social media message, a grievace submitted from a commuity, a first ews report), a guidig time lie for actio for the first 24 hours, 3 days, 1 week, 1 moth, a descriptio of how ad whe ivestigatios will occur, a list of stakeholders: those who make decisios; those who should be cosulted; those who take actio; those who should be kept iformed, a process for desigatig ad traiig a spokesperso, a process for updatig ad distributig talkig poits, a geeral list of agreed strategies, activities ad chaels for commuicatio (e.g. stakeholder meetigs, holdig statemets, ews release, ews coferece, radio programmes), methods to liste to the views ad cocers of all groups, ad egage with them for example, prepare how to moitor public cocers through commuity cotacts, the media ad social media, ad a moitorig ad evaluatio pla. 6. Resources icludig: a listig of facts that will help with messagig, icludig the baselie evidece o AEFIs for differet vaccies 22 ; cotact lists for all stakeholders who eed regular updates; for media; ad of ifluetial champios for immuizatio (such as reproductive health or cacer specialists). Esure traiig ad orietatio for key stakeholders. Whe stakeholders have iformatio i advace, they kow what ormal issues to expect, how to commuicate about potetial problems, ad what to do if oe occurs. Those requirig traiig ad orietatio iclude: 1. Health workers who should be fully aware of ormal AEFIs ad how to commuicate them to teachers, caregivers ad girls; how to avoid them; what to do ad who to cotact if oe occurs. 2. Headmasters, teachers who should also be aware of ormal AEFIs, how to commuicate with girls; how to help with immuizatio maagemet (e.g. esurig girls sit quietly after vacciatio); ad who to call should a serious AEFI occur. 3. Commuity leaders who should be aware of ormal AEFIs, how to commuicate them to the commuity ad who to call should a serious AEFI occurs. 22. Reliable sources of iformatio iclude WHO s fact sheets: ad positio papers:

68 HPV Vaccie Commuicatio: Special cosideratios for a uique vaccie 2016 update 4. Jouralists who should be fully orieted o several aspects of HPV vaccie before it is itroduced: its purpose, ratioale for target age group, safety record, impact, itroductios i other coutries icludig commo rumours, ormal AEFIs, ad who to cotact for iformatio. Tip»» Maitai good relatioships with jouralists who ca help to report accurate iformatio should there be a crisis. Implemet: whe crisis occurs Where ad whe to respod? The prime commuicatio objectives durig vaccie-related crises are: to uderstad ad maage the cause of the crisis so there are o further risks to people s health, the immuizatio programme or the health system, to maitai ad restore trust ad cofidece i immuizatio, if damaged, restore trust ad cofidece i the immuizatio programme i the medium ad log term. Be proactive Aim to stop the crisis before it gets large. Activate the crisis commuicatio committee ad pla. Aalyse Lear ad cofirm what is happeig: What has happeed? Collect iformatio from trusted sources. Why is it happeig? Where is this happeig i a sigle commuity, regio, atioally? Aalyse why ad how it will affect the programme. Is this a low, medium or high impact evet? Is the crisis gettig public attetio ad affectig public trust i vaccies? Does it require a ivestigatio? If so, this should happe rapidly. 60

69 crisis commuicatio for HPV vaccie Tailor the strategy to the situatio. If, for example, the crisis is ot receivig public attetio, a local meetig with the commuity may be adequate. If the crisis is causig atiowide axiety, the commuicatio pla requires a rapid atioal respose. Set specific commuicatio objectives for example, to stop a rumour, chage behaviours, protect the public, call for collective actio. Idetify target audieces ad uderstad their cocers, iformatio ad egagemet eeds. Decide how best ad how ofte to commuicate with the target audieces. Desigate a respected ad traied spokesperso if the crisis requires a public respose. People ted to trust scietists ad experts more tha politicias. The spokesperso should be traied by a expert. They must take part i all crisis-related meetigs, ad coordiate updated talkig poits. They should be the sole source of iformatio for jouralists. Coordiate Betwee techical ad commuicatio experts With other relevat parties such as local health uits ad schools If i doubt, commuicate From a public trust stadpoit, it is better to provide too much iformatio tha too little. Take cotrol of the story by commuicatig first rapidly, proactively, accurately ad trasparetly. Silece ca be perceived as a admissio of guilt. Iformatio voids will be filled by others who may ot have the public iterest at heart. Goig public Timig: the public aoucemet should be timely (e.g. withi a day) ad parters should be advised whe it s happeig so they are prepared Trasparecy: messages should be jargo-free, factually accurate, up-to-date ad iclude ay relevat calls to actio Iform core stakeholders before goig public, so they are ot take by surprise Prepare ad update iformatio ad materials regularly. Make public iformatio available o a website ad/or i social media. Materials ca iclude: key messages appropriate to each audiece about health risks, ucertaities ad actios to take to protect oeself, 61

70 HPV Vaccie Commuicatio: Special cosideratios for a uique vaccie 2016 update talkig poits, updated ad circulated regularly to everyoe who eeds them, frequetly asked questios, ews releases ad holdig statemets, ad materials for miority laguage groups. Use empathetic laguage people wat to kow you uderstad their cocers, eve if they prove to have o basis i evidece. Whe you do ot have all the iformatio or aswers, say so it is ok to tell the public that you do t kow, but the fid out ad follow up rapidly with more iformatio. Liste to the public ad their cocers update messages to address these through media statemets or commuity meetigs. Dismissig cocers ca push people towards ati-vaccie groups ad stregthe that voice. Cosider settig up a hotlie with traied staff who ca aswer questios. Respect the huma rights of all groups. For example, do ot stigmatize specific groups as the importers or carriers of disease. As the crisis cotiues Cosider quatity ad timig of iformatio provide cosistet regular updates so that stakeholders kow what to expect. These may be daily at first, ad the bi-weekly, ad weekly depedig o the ature of the crisis. Have regular eve daily coordiatio meetigs with the crisis team to discuss progress, cocers, roles, resposibilities ad strategies. Esure stakeholders cotiue to receive updated iformatio icludig advace otice of media briefigs. Cotiue to liste to the public ad address their cocers. Moitor the pla adjust, update ad provide iformatio as it evolves. Whe the crisis is over: aouce, aalyse, update Make a aoucemet that the crisis is over whe it truly is over do ot make premature statemets. Assess what lastig impact it might have o the immuizatio programme, ad make plas to address ay potetial ogoig cocers. This ca iclude a updated commuicatio pla if the crisis will affect the immuizatio programme for the medium ad log term. 62

71 crisis commuicatio for HPV vaccie Tip: Developig key messages for crises Key messages are short statemets desiged to commuicate essetial iformatio ad poits, icludig ecessary actios to the public, ews media, or health workers. They reflect the essetial iformatio you wat to covey ad ca also fuctio as soud bites durig media iterviews. Havig key messages prepared i advace will allow you to commuicate quickly ad effectively. Poits to cosider whe developig key messages: List the 3 or 4 thigs you really wat health workers, the public or the media to kow, ad the actios they should take. Esure the key messages:»» are specific, clear ad cocise,»» use words ad examples that your audiece will uderstad,»» iclude clear iformatio about what the public should ad should ot do,»» avoid jargo ad techical terms,»» are backed up with supportig facts ad evidece, ad»» are positive talk about what you are doig, ca ad will do; ot what you caot. Tip: The audieces to cosider throughout a crisis The Miister of Health, other relevat Miistries ad seior govermet/policy staff do they agree with the pla? Do they have specific cocers? I a large crisis, the head of state may eed to be ivolved. Political ad other oppositio: provide them with correct iformatio i a timely maer, proactively meet with key leaders to explai the situatio. Health workers: is their role clear? Are they armed with the right iformatio to address ad help maage the crisis? Do they kow about AEFIs? Commuicate with them early ad ofte. Professioal associatios: icludig paediatricias, ocologists ad gyaecologists. Parters: what is the pla to discuss issues with them ad provide iformatio? How ca they help to maage the crisis? Jouralists ca help to maage a crisis with correct, timely iformatio but ca also spread rumours quickly if they are misiformed. Media may have a low uderstadig of what vaccies are for ad how they work. They may favour publicizig the egative aspects of the story. Be proactive ad give them the factual iformatio they eed to report the story. Meet with media regularly to provide trasparet updates. As part of the ogoig commuicatio pla, foster relatioships with key media so they have a good uderstadig of vaccie issues. Traditioal ad religious leaders: what are their beliefs? Do they have questios or cocers? How ca they be egaged to address these ad help to iform their commuities? Commuities: which commuities are most cocered? Why? How are they beig heard? Cosider workig directly with them to help address cocers ad curb the crisis. Sub-groups withi commuities: cosider at-risk miorities, wome, ad people with disabilities. 63

72 HPV Vaccie Commuicatio: Special cosideratios for a uique vaccie 2016 update Cautios ad lessos from global experiece with HPV vaccie Despite global scietific evidece uderscorig the HPV vaccie s safety ad cotiued reassurace about the safety profile of the HPV vaccies, there have bee serious crises with HPV vaccie programmes i a hadful of coutries, maily with perceived AEFIs liked temporally, but ot causally to HPV vaccie. 23 The Uited Kigdom Avertig a potetial crisis withi 24 hours The situatio I the Uited Kigdom i September 2009, there were reports that a 14-yearold girl had died withi hours of a HPV vacciatio. Local school authorities icorrectly set a correspodece (later corrected) to parets that said the girl had died due to a rare, but extreme reactio to the vaccie. The respose The local health authorities rapidly issued a statemet icludig the facts of the deaths, expressed sympathy with family ad frieds, ad aouced a full ivestigatio would be immediately udertake. The statemet also wared that o lik ca be made betwee the death ad the vaccie util all the facts are kow ad a post-mortem takes place. Media officers briefed jouralists with whom they had relatioships ad urged them ot to speculate about the story. A prelimiary post-mortem showed the girl had died due to a rare, uderlyig coditio ad that the vaccie played o role. Withi miutes, commuicatio officers cotacted media with this iformatio, i time for the 10 p.m. atioal eveig ews. The govermet cotiued to fully back the HPV vaccie. By the followig day, media iterest i the story tapered off. 24 Japa s HPV vaccie story The situatio I Japa i March 2013, reports liked HPV vaccie to a series of adverse evets i about 50 girls, icludig complex regioal pai sydrome. Victims groups emerged to provide their stories ad the media was quick to report these, despite o evidece likig the adverse evets with the vaccie. A local authority provided compesatio to those claimig their daughters had bee affected, thus suggestig a causal lik. Ati-vaccie groups gaied cotrol of the arrative ad the loss of public cofidece i HPV vaccie has resulted i extremely low coverage. Cervical cacer vaccie victim braches expaded i the coutry. Evidece of HPV vaccie s safety, published by the Global Advisory Committee o Vaccie Safety, were ever published i the media. 23. For more o HPV vaccie safety, see reports from the Global Advisory Committee for Vaccie Safety, published at: it/vaccie_safety/committee. 24. For more o this case, see the WHO s Case Study C: How a potetial HPV vacciatio crisis was averted, which is part of a Vaccie Safety Basics E-learig course: (accessed August 2015). 64

73 crisis commuicatio for HPV vaccie The respose I Jue 2013, the Vaccie Adverse Reactios Review Committee met ad Japa s Miistry of Health, Labour ad Welfare decided to temporarily susped recommedatio of HPV vaccie. Health authorities were istructed to o loger actively recommed or promote the vaccie, though it is still available by request. Util early 2016, this decisio remais ad results of ay ivestigatios have ot bee made public. The result Public trust i the vaccie is eroded ad HPV vaccie coverage is very low. News from Japa has reached other coutries, where it has had a impact o the kowledge ad beliefs about HPV vaccie amogst some commuities. The evidece ad lessos A group of researchers who recorded a dramatic decrease i HPV vaccie coverage i oe Japaese city oted that: No vaccie safety sigal has bee recorded i Japa. Istead, idividuals who have the misfortue to be uwell with rare or difficult to treat disorders have bee ecouraged by ati-vacciatio advocates to blame the HPV vaccie, especially i a urestraied media eviromet ad with little reassurace ad systematic addressig of these evets by the govermet. I March 2014, the Global Advisory Committee o Vaccie Safety (GACVS) issued a statemet to stress that it had ot foud ay safety issue that would alter ay of the curret recommedatios for use of the vaccie. The GACVS oted its cocer by the claims of harm that are beig raised o the basis of aecdotal observatios ad reports i the absece of biological or epidemiological substatiatio. The committee cotiued that allegatios of harm from vacciatio based o weak evidece ca lead to real harm whe, as a result, safe ad effective vaccies cease to be used. 25 The 2014 GACVS statemet was ot reported i the Japaese media. 26 I December 2015, the GACVS addressed the issue of Japa agai ad stated that review of cliical data by the atioal expert committee led to a coclusio that symptoms were ot related to the vaccie, but it has ot bee possible to reach cosesus to resume HPV vacciatio. As a result, youg wome are beig left vulerable to HPV-related cacers that otherwise could be preveted For the full text of the GACVS statemet, see: Mar_2014.pdf (accessed Jauary 2016). 26. For a summary of the case i Japa see two publicatios from the CSIS Global Health Policy Ceter, both authored by Rose Wilso et. al. HPV Vacciatio i Japa, 2014 ad Both ca be dowloaded here: (accessed Jauary 2016). 27. For the full text of the latest GACVS statemet see (accessed Jauary 2016). 65

74 HPV Vaccie Commuicatio FAQ, materials & resources

75 Frequetly asked questios These Frequetly Asked Questios (FAQ) are adapted from WHO s Comprehesive Cervical Cacer Cotrol Guide. 28 About HPV Questio: What is HPV? Aswer: Huma papilloma virus, or HPV, is a commo virus that is easily spread by ski-toski sexual cotact with aother perso ivolvig geital ski, eve without sexual itercourse. Most HPV-ifected people have o sigs or symptoms, so it is possible to spread the ifectio to aother perso ukowigly. Most HPV ifectios are elimiated by the body i the first few years. Those that are ot elimiated are termed persistet ad may cause cervical cacer. Questio: Why are HPV vaccies eeded? Aswer: HPV vaccies are eeded because they greatly reduce the occurrece of cervical cacer, a pricipal cause of death from cacer amog wome i less developed coutries. 28. WHO, Comprehesive Cervical Cacer Cotrol: A guide to essetial practice, 2d Editio, December 2014, pg. 222, who.it/reproductivehealth/publicatios/cacers/cervical-cacer-guide. 67

76 HPV Vaccie Commuicatio: Special cosideratios for a uique vaccie 2016 update Questio: Do all wome with HPV ifectio get cervical cacer? Aswer: No. I most wome, HPV ifectios are elimiated by the body i the first few years. Amog may differet types of HPV oly a few ca cause cervical cacer if they are ot elimiated by the body ad persist for years. Of the group of HPV viruses that cause cervical cacer, two of these HPV types 16 ad 18 are the cause of 7 out of every 10 cervical cacers. Ifectio with these two HPV types ca be preveted by HPV vacciatio, so these vaccies ca protect agaist 70% of cervical cacer if give as recommeded. I additio, cervical cacer ca be preveted amog wome who have HPV ifectio if they participate i screeig ad treatmet. If wome aged years are screeed for chages i the cells of the cervix (pre-cacer), which are caused by persistet HPV ifectio, ad treated as eeded, the cervical cacer deaths would become rare eve though HPV is commo. Questio: How commo is cervical cacer caused by HPV? Aswer: HPV is the mai cause of cervical cacer. There are cases of cervical cacer diagosed each year. Of the wome who die every year from cervical cacer i the world, the great majority live i developig coutries. About HPV vacciatio Questio: Will the HPV vaccies keep my daughter from gettig cervical cacer? Aswer: Yes. The HPV vaccies prevet ifectio with the two types of HPV that cause most cervical cacers. All sexually active people should also practise behaviours that prevet the spread of sexually trasmitted ifectios (e.g. delayig iitiatio of sexual activity, usig codoms, ad havig as few sexual parters as possible). Wome who have bee vacciated should also be screeed for cervical cacer whe they are older. Questio: What are the WHO prequalified HPV vaccies curretly available? Aswer: As of Jauary 2016, two HPV vaccies are curretly prequalified by WHO. These vaccies are: Cervarix (made by GlaxoSmithKlie) ad Gardasil or Silgard (made by Merck). Questio: How are the two HPV vaccies similar? Aswer: Both vaccies provide very effective protectio agaist 70% of potetial cases of cervical cacer (because they both target HPV types 16 ad 18). Both vaccies are very safe. Both vaccies caot cause disease because they do t cotai live viruses. Both vaccies are give as ijectios (shots) ad require two doses for girls youger tha 15 years old, ad three doses for immuo-compromised girls (icludig those kow to be livig with HIV) ad for girls aged 15 years ad older. 68

77 faq, materials ad resources Questio: How are the two HPV vaccies differet? Aswer: The vaccies are made up of differet compoets to icrease the body s productio of atibodies. Oe vaccie (Gardasil or Silgard ) also provides protectio agaist geital warts (because it also targets HPV types 6 ad 11). Questio: Who should get vacciated? Aswer: WHO recommeds that girls should be vacciated whe they are aged 9 13 years. The vaccies are ot recommeded i girls youger tha 9 years of age. Questio: What is the recommeded schedule (or timig) of the two-dose HPV vaccie schedule? Aswer: Two doses (shots/ijectios) are recommeded for girls below 15 years of age, the secod dose six moths after the first. The provider who gives the vaccie will iform each girl who is vacciated (ad her parets) whe she eeds to retur for the fial dose. There is o maximum iterval betwee the two doses; however a iterval of ot greater tha moths is suggested. If the iterval betwee doses is shorter tha five moths, the a third dose should be give at least six moths after the first dose. Questio: What is the recommeded timig of the three-dose HPV vaccie schedule? Aswer: Whe three doses are recommeded (i.e. for girls aged 15 years or older, ad for those kow to be immuo-compromised ad/or HIV-ifected, regardless of whether they are receivig atiretroviral therapy), the secod dose should be received oe or two moths after the first dose (depedig o the type of vaccie), ad the third dose should be received six moths after the first dose. The provider who gives the vaccie will iform each girl who is vacciated (ad her parets) whe she eeds to retur for the ext or fial dose. It is ot ecessary to scree for HPV ifectio or HIV ifectio prior to HPV vacciatio. Questio: Ca HPV vaccies cure or get rid of HPV ifectios or cervical cacer, if a girl or woma is already ifected with HPV whe she gets the vaccie? Aswer: No. A HPV vaccie caot cure HPV ifectios that may be preset i a girl whe she is vacciated; either ca it cure cervical cacer or pre-cacer abormalities, or prevet progressio of disease i wome who are already ifected with HPV whe they receive the vacciatio. Questio: Will a woma betwee the ages of 30 ad 49 years still eed to be screeed for precacer ad cacer eve if she was fully vacciated whe she was a girl? Aswer: Yes! It is very importat for adult wome to get cervical cacer screeig whe they are years old, eve if they were previously vacciated. This is because although the vaccie is very effective, it does ot prevet ifectio from all types of HPV that cause cervical cacer. 69

78 HPV Vaccie Commuicatio: Special cosideratios for a uique vaccie 2016 update Questio: Ca girls who are livig with HIV be vacciated? Aswer: Yes! Studies show that HPV vaccie is safe to admiister to girls who are livig with HIV. Vacciatio for these girls is recommeded prior to sexual debut, just as it is for all other girls. Girls who are livig with HIV or are otherwise immuo-compromised should receive three doses of HPV vaccie at 0, 1 2 ad 6 moths, whether or ot they are already 15 years old. Questio: Why are boys ot vacciated? Aswer: The vaccie ca protect boys from aal, peile, mouth ad throat cacers, which are far less commo tha cervical cacer. Some developed coutries with larger health budgets are vacciatig boys. However, at the momet WHO does ot recommed vacciatig boys as a priority because the vaccie is costly ad to have the largest public health impact ad prevet cervical cacer it s more effective to focus o reachig high coverage amog girls. Commo worries about HPV vacciatio Questio: Are the HPV vaccies safe ad effective? Aswer: Yes. May studies coducted i developig ad developed coutries have foud both vaccies to be very safe ad effective. Both vaccies have bee admiistered to millios of girls ad wome aroud the world without serious adverse evets. As with all vaccies, the safety of these vaccies is moitored very carefully. Commo, mild adverse reactios iclude pai ad redess where the shot was give, fever, headache ad ausea. Sometimes girls who get the HPV vaccie (or other vaccies) fait, so girls should be watched for 15 miutes after vacciatio; if they feel fait they should lie dow to avoid gettig hurt. Questio: Why do people fait after gettig HPV vaccies? Aswer: Adolescets are particularly proe to faitig after ay medical procedure, icludig receivig vaccies, because they are ofte very ervous before comig ito the vacciatio room. To prevet falls ad ijuries due to faitig, ask the girl receivig the vaccie to be sittig before, durig ad for 15 miutes after the vaccie is give. Questio: My daughter is too youg to be havig sex why is HPV vaccie recommeded for such youg girls? Aswer: For the HPV vaccie to work best, it is very importat to vacciate girls before they have ay sexual cotact with aother perso. 70

79 faq, materials ad resources This is because a youg girl ca be ifected with HPV eve the very first time she has sexual cotact (eve just ski-to-ski cotact ear the vagia ad peis). Also, tests have show that the vaccie produces better protectio from HPV ifectio whe give at this age compared to older ages. The vaccies caot treat a girl who is already ifected with HPV. Questio: Will HPV vacciatio affect my daughter s fertility? Will it be more difficult for her to become pregat or to carry a pregacy to term? Aswer: No! There is o evidece that HPV vacciatio will affect a girl s future fertility or cause ay problems with future pregacies. Questio: Are all recommeded doses eeded for my daughter to be fully protected from HPV? Is oe dose ot eough? Aswer: Like some other vaccies, the HPV vaccie requires more tha oe ijectio. Without all the recommeded doses, the vaccie might ot be completely effective i prevetig cervical cacer. It is importat that a girl receives all doses ad observes the miimum ad maximum itervals betwee the doses, i order to be fully protected. Questio: Is HPV vaccie safe i pregacy? Aswer: HPV vaccies are ot recommeded for use i sexually active or pregat girls or wome. However, studies have show that the vaccie causes o problems for the mothers or the babies bor to wome who received the HPV vaccie durig pregacy. If a girl or woma receives the HPV vaccie whe pregat, this is ot a reaso to cosider edig a pregacy. But, to be o the safe side, util more is kow, girls ad wome should ot be vacciated while pregat. Questio: Are there ay cotra-idicatios to beig vacciated? Aswer: If a girl has had a serious allergic reactio to aother vaccie or a previous dose of the HPV vaccie, the she should ot receive HPV vaccie, to avoid serious reactios. 71

80 HPV Vaccie Commuicatio: Special cosideratios for a uique vaccie 2016 update Materials Samples of materials The followig are examples of HPV vaccie commuicatio material produced i Malaysia, Rwada ad Latvia. 72

81 faq, materials ad resources Examples of HPV vaccie websites with sample materials Note that coutry HPV vaccie immuizatio policy may vary by target age, geder ad doses required. Argetia has a FAQ ad presetatio i Spaish about HPV vaccie ad the prevetio ad cotrol of cervical cacer: article/46/185-vph. Brazil has may materials icludig posters, spots for radios, ad videos: saude.gov.br/idex.php/cidadao/pricipal/campahas-publicitarias/15888-vaciacao-cotra-ohpv The Caadia provice of Otario has iformatio for parets ad girls: o.ca/e/ms/hpv. Frace s miistry resposible for health icludes iformatio about HPV vaccie i the cotext of cervical cacer prevetio ad cotrol, ad icludes iformatio targeted at the public ad health professioals: papillomavirus-humais-hpv-et-cacer-du-col-de-l-uterus-prevetio-depistage. Malaysia s health miistry worked with atioal religious authorities who issued a fatwa to support HPV vacciatio. The Bahasa versio is here: The Uited Kigdom s Natioal Health Service site icludes IEC materials ad a FAQ: The U.S. Ceters for Disease Cotrol ad Prevetio site icludes a FAQ ad other iformatio: 73

82 HPV Vaccie Commuicatio: Special cosideratios for a uique vaccie 2016 update Resources Cervical cacer ad HPV vaccie WHO s Comprehesive Cervical Cacer Cotrol: A Guide to Essetial Practice, 2d editio, December WHO s HPV Vaccie Itroductio Clearighouse icludes comprehesive iformatio which helps programme ad commuicatio maagers lear, pla, target, deliver ad commuicate about HPV vaccie itroductio: RHO Cervical Cacer is a site aimed at decisio makers ad programme plaers i low-resource settigs. It provides several resources o HPV vaccie itroductio, commuicatios plaig ad lessos, icludig from PATH s HPV vaccie pilot projects i Peru, Ugada ad Viet Nam ad the 2015 PATH/LSHTM HPV Vaccie Lessos Leart & Recommedatios: Commuicatio for immuizatio WHO Euro has liks to several excellet resources, icludig for advocacy, ad tailorig immuizatio: Commuicatio for developmet UNICEF has published a set of guides o plaig, moitorig ad evaluatig commuicatio for developmet activities: Johs Hopkis Uiversity Ceter for Commuicatio Programs offers several liks to commuicatio plaig, implemetatio ad moitorig resources: The Commuicatio Iitiative is a commuicatio for developmet commuity ad its website icludes several resources: Crisis commuicatio WHO Europea Regioal Office s 2013 guide: Vaccie Safety Evets: Maagig the Commuicatio Respose. A Guide for Miistry of Health EPI maagers ad Health Promotio Uits WHO EURO A WHO e-learig course etitled Vaccie Safety Basics provides cases studies ad practical advice: Formative research PATH s Coductig Formative Research for HPV Vacciatio Program Plaig offers practical guidace from PATH: A guide for developig kowledge, attitude ad practice surveys from WHO/Stop TB Partership provides a step-by-step guide to coduct a KAP survey. While the examples are most relevat to tuberculosis cotrol, 74

83 faq, materials ad resources the steps are relevat to udertakig ay KAP survey about a public health topic. publicatios/2008/ _eg.pdf The coset process WHO s Cosideratios regardig coset i vacciatig childre ad adolescets betwee 6 ad 17 years old provides additioal guidace to coutries o the issue of coset ( ) ; ad the PATH/ LSHTM HPV Vaccie lessos leart & recommedatios also provides data o HPV vaccie coset i coutries ( All liks were accessed i Jauary

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