Module 6 Communicating about HPV Vaccine with Stakeholders CervarixTM Essential Training Package for HPV Vaccine Introduction Module 6 Communicating about HPV Vaccine with Stakeholders CervarixTM

Learning objectives At the end of the module, you will be able to: Describe the key stakeholders  Describe how to communicate with these stakeholders (teachers, parents and girls) Describe key messages on Cervical cancer and HPV vaccination to stakeholders, using Triple “A” Duration 20’

Key issues 1 2 3 4 Who are the key stakeholders? How to communicate with stakeholders? 2 Using 'Triple A' to remember to give right messages? 3 What are the key messages for stakeholders on Cervical cancer and HPV vaccination? 4 Explain to the participants the key issues raised in this module: We will provide you with answers to the following questions: Who are key stakeholders? How does one communicate with each of these stakeholders? What are the key messages to give to stakeholders on cervical cancer and HPV vaccination? How does one advise on potential side effects?

Who are key stakeholders? Are there other specific stakeholders or gatekeepers in your community? 1 2 3 Explain to the participants who are key stakeholders: There are 3 key stakeholders for HPV vaccination teachers, parents and girls aged from 9-13 years old. Discuss the reasons why they are important. Note that the importance of teachers may depend on the delivery strategy that is being followed for the vaccination – even when the delivery is not (exclusively) school based, remember that teachers are influential members in the community. Raise question: “ Are there other specific stakeholders or gatekeepers in your community? “  In some communities, religious leaders are some of the groups that can influence people to support HPV vaccination. They will likely need the same information as teachers. If vaccinations will be carried out at schools, parents are likely to be absent. Teachers therefore will become a conduit for the right information as they get questions from parents and need to be comfortable answering them. Teacher Parents Girl

How to communicate with stakeholders: teachers Be respectful Use simple words and avoid technical terms Make sure the teacher has understood your key messages Tell teachers they can play an important role by: Listening to and addressing the concerns of parents Educating girls on the benefits of HPV vaccination Helping with the organization on the HPV immunization session Involve teachers as partners in HPV vaccine communication Explain to the participants how to communicate with teachers: In order to ensure good communication with teachers the health worker should : Be respectful: smile often, be friendly Use simple words to provide information on cervical cancer and HPV vaccination. You should avoid using technical terms Make sure that teachers have understood your key messages. Reword and simplify if needed Remind teachers of the contribution they can make to HPV vaccination programme, including working with health workers to have all eligible girls vaccinated, mobilizing all eligible girls for HPV vaccination, listening to and addressing parents’ concerns described in the next slide. (note that in some countries teachers may have been assigned specific roles in the vaccination campaign, in which these cases are described in the agreement between the health and education authorities) Involve teachers as partners in HPV vaccine communication in their communities

How to communicate with stakeholders: parents Be respectful Use simple words and avoid technical terms Make sure parents have understood your key messages Listen and address their concerns Involve parents as partners in HPV vaccine communication Explain to the participants how to communicate with parents: The health worker should always: Be respectful: smile often, be friendly Use simple words to provide information on cervical cancer and HPV vaccination. You should avoid using technical terms Make sure that parents have understood your key messages. Reword and simplify if needed Listen to parents’ concerns. Sometimes parents have fears that are unfounded. Examples of such fears are: Girls may perceive consent to vaccination as implicit approval from their parents for them to be sexually active The vaccine will make girls more likely to have sex earlier, or to have unprotected sex or affects a girl’s sexual behavior in other ways The vaccine may affect the fertility of the girl Address parents’ concerns: Reassure parents that careful research has shown that HPV vaccine is safe and effective and that the HPV vaccine does not have any effect on sexual behavior or fertility Involve parents as partners in HPV vaccine communication by talking to other members in the community

How to communicate with stakeholders: girls (1/2) Be respectful; a good way to do so is to introduce yourself Use simple words and avoid technical terms Make sure the girls have understood key messages Ask the girls if they have any questions Listen and address their concerns Explain to the participants how to communicate with girls: To effectively communicate with girls, health workers must first understand their concerns regarding HPV immunization and understand factors that can lead to misinformation about the safety and effectiveness of the vaccine. Healthcare workers should establish an open, friendly dialogue with girls and provide clear answers to their questions and provide accurate information about vaccination. To establish a good rapport with the girls the health worker should : Be respectful: A good way of doing that is to introduce yourself. Smile often, be friendly Use simple words to make sure the girl understands your key messages You can ask the girl what she has understood, and if needed you can reword and simplify your messages Allow the girl to express her concerns: actively ask if the girls have any questions or concerns. Remember that adolescents may be reluctant to ask and that short term consequences like pain may be more relevant to an adolescent compared to benefits of the vaccine in future Answer all questions factually. When you get questions related to sexuality or fertility, make sure that your own beliefs do not interfere with how and what you answer to the girls

How to communicate with stakeholders: girls (2/2) Encourage girls to get vaccinated If girls are reluctant, take the time to listen and understand their fears and/or source of misunderstanding Recognize that girls have the right to refuse to get vaccinated Never force or trick a girl into getting vaccinated Allow the girls to take part in decision making about vaccination Involve girls in reaching out other girls in the community that maybe eligible for HPV vaccination Motivate the girls to get vaccinated. If a girl is reluctant to have the vaccine, find out what fears she has and address them. If a girl refuses, remember that she has the right to refuse. While it is good to explore if there are ways to convince her, never force or trick a girl into getting vaccinated Allow the girls to take part in the decision making about vaccination. Giving them a chance to be involved in HPV vaccination shows that you are taking them seriously You can involve the girls by motivating them to talk to other eligible girls in the community about the benefits of HPV vaccination– particularly those who do not go to school

“Triple A” communication to deliver key messages to stakeholders Advise on what is given Alert on side effects and how to respond Arrange for when to return Describe to the participants what the concept of triple A communication with teachers, parents and girls: Triple A is a mnemonic system/memory trigger that allows health workers to remember the three areas of content that need to be covered when communicating with teachers, parents and girls: A A A as Advise, Alert, and Arrange. Advise: Health workers should advise teachers, parents and girls on the disease prevented, characteristics, doses, schedule of the vaccine etc. Alert: Health workers should alert teachers, parents and girls about the potential side effects after immunization and how to respond Arrange: Health workers should arrange with teachers, parents and girls the next appointment for administering the subsequent doses to complete the schedule

Advise: Cervical cancer (1/4) Cervical cancer is the second most common cancer among women in developing countries Cervical cancer is most often caused by a virus called Human Papillomaviruses (HPV) HPV is a common virus that is easily spread by skin-to-skin contact during sexual activity with another infected person HPV types 16 and 18 cause 70% of all cervical cancer cases Most young people are typically infected soon after they become sexually active. Most HPV infections are asymptomatic It takes between 10 to 20 years for Cervical Cancer to develop after HPV infections but can occur much more quickly in people with weak immune systems, like in women with untreated HIV infection Explain to the participants how to inform about cervical cancer: Key messages for teachers, parents, and girls include: Although cervical cancer is one of the most preventable cancers, it is the second most common cancer among women in developing countries where routine cervical cancer screening is not widely available. Every year, more than 260 000 women die from cervical cancer Cervical cancer comes from a virus called the Human Papillomavirus (HPV) It is a common virus that is easily spread by skin-to-skin contact during sexual activity with another infected person 70 percent of cervical cancer worldwide are caused by only two HPV types 16 and 18 Most young people are typically infected soon after they get sexually active Cervical cancer develops slowly many years after (usually between 10 to 20 years) HPV infection. In people with weak immune systems, women with untreated HIV, cervical cancer may develop more rapidly. In most cases, there is no sign that a person is infected with HPV

Advise: Prevention of HPV infection and Cervical cancer (2/4) Sexual education HPV Vaccination PREVENTION Cervical screening Prevent or stop tobacco use Consistent condom use Explain to the participants the main messages for prevention of Cervical Cancer: Prevention methods against cervical cancer for girls and women include HPV vaccine for girls aged 9-13 years old, sexuality education, prevention of tobacco use and cessation if relevant, consistent use of condoms, and cervical cancer screening for women between 30 and 49. Currently, there are two HPV vaccines licensed and available worldwide, inlcuding Gardasil TM and Cervarix TM. Both HPV vaccines work best if given to young girls before they become sexually active. The WHO recommends the vaccination of girls between 9 and 13 years old. HPV vaccines will not treat or get rid of existing HPV infections. Also, HPV vaccines do not treat or cure health problems (like cancer or warts) caused by an HPV infection that was acquired before vaccination. Adult women should get cervical cancer screening even if they have completed HPV vaccination. 11

Advise: HPV vaccine (3/4) The vaccine is very safe and effective Millions of girls and women around the world have received HPV vaccine without serious side effects As of mid 2015, HPV vaccine has been introduced in more than 50 countries The vaccine works against Cervical Cancer but does NOT prevent pregnancy does NOT prevent HIV or other sexually transmitted infections Explain to the participants if HPV vaccine is safe : This vaccine offers the best protection against HPV injection! Most national regulatory agencies, including the Food and Drug Administration in the U.S.A. and the European Medicines Agency, have licensed the vaccines and note them to be safe and effective The vaccine has been administered to millions of girls and women around the world without serious side effects As of mid 2014, HPV vaccine has been introduced into the national immunization program in more than 50 countries The vaccine works against Cervical Cancer. The vaccine does NOT prevent pregnancy, HIV, or other sexually transmitted infections

Advise: HPV vaccine schedule (4/4) CervarixTM dosing schedule HPV vaccine is delivered in 2 doses over a period of at least 6 months Dose 1 Dose 2 CervarixTM dosing schedule Explain to the participants how to vaccinate the girl against HPV: Explain to the teachers, parents and girls that it is important to get the complete series of 2 doses of HPV vaccine with at least 6-months between the first and second doses HPV vaccine will be given in the form of an injection in the muscle of the upper arm (right or left arm) Minimum interval of 6 months

Alert: Description of side effects No serious side effects have been reported Common minor side effects are redness, pain and swelling at the injection site Less common minor adverse events include fever, dizziness, and nausea Syncope or fainting after injection is more common in adolescent girls but not related to HPV vaccine If a girl shows any unusual symptoms after vaccination, take her directly to the hospital Explain to the participants how to respond to side effects: Current HPV vaccines are generally well tolerated Pain and swelling where the injection was given are very common side effects of HPV vaccine Other minor adverse events include fever, dizziness, and nausea Syncope – fainting - not related to HPV vaccine but to needles/blood is more common in adolescents than in other ages. This is unrelated to the vaccine itself. To prevent possible syncope, it is recommended that adolescents be seated or lie down during HPV vaccine administration. Girls who feel faint/weak after the vaccination should remain seated or laying down for 15 minutes before getting back on their feet If a girl has fever (>39˚C), paracetamol may be given If the girl shows any unusual symptoms, take her directly to the hospital or contact the health worker who administered the vaccine  Teachers, parents and girls have to understand that the risk of the side effects after HPV vaccination is much lower than the future risk of Cervical Cancer.

FAQs (1/2) 1 2 3 4 Does HPV vaccine affect fertility? Does HPV vaccine affect sexual behavior? 2 Can HPV infection be treated? 3 What is the role of boys and men in HPV prevention? 4 Read the situation and question to the participants: Response: Question 1: No, HPV vaccine does NOT affect a girl's fertility (the ability to bear children) Question 2: No, HPV vaccine does NOT affect a girl’s sexual behavior or orientation Question 3: There is no antiviral treatment for HPV infection. But there are treatments for the health problems that it can cause, including treatment for precancerous cervical lesions and cancerous cervical lesions Question 4: The current vaccination programme is for prevention of cervical cancer, which only affects women. Boys and men should know how to help protect their female partners and their daughters against cervical cancer. Key prevention measures are condom use with female partners, promotion of HPV vaccination in girls and daughters and promotion of screening for older women 15

FAQs (2/2) Why is HPV vaccine given to girls 9-13 years of age if cervical cancer affects women later in life? 5 Can older women get HPV vaccine? 6 Who should get the vaccine? 7 Read the situation and question to the participants: Response: Question 5: Cervical cancer takes a long time to develop (usually between 10 and 20 years) after HPV infection. Most HPV infections occur quickly after the start of sexual activity; Therefore, it is important to vaccinate girls before HPV infection can first occur. The vaccine is also most effective in girls aged 9-13 years old. Question 6: HPV vaccine is not recommended beyond early adolescence. There are other steps older women can take to lower their risk of cervical cancer such as, using condom, and going for cervical cancer screening. They can also reduce cancer risk by not using tobacco. Question 7: All eligible girls in the age group of 9-13 years should get the vaccine even if: they have started their monthly periods (menstruation) they have HIV ( in which case they need 3 doses) 16

Arrange: ensure completion of the immunization schedule Inform girls when they should receive the next HPV vaccine dose Write the date of the next dose on their immunization card Remind girls to come on the specified date and to bring their immunization card Tell teachers and parents to remind girls of the next vaccination date Explain to the participants when to return for the second and third dose: Inform the girls when to get the next HPV vaccine dose Write the date of the next visit on the immunization card Remind the girls to come on the specified date and to bring the card Remind teachers and parents to inform the girls some days before the next immunization session about the next dose

Key messages Applying the basic principles of good communication ensures that main messages will be understood by teachers, parents, and girls: Show respect Use simple terms Verify correct understanding Address concerns Enable involvement Using “Triple A” communication (Advise, Alert and Arrange) helps health workers to convey the correct messages on Cervical cancer, its prevention, and the correct administration of HPV vaccine Explain to the participants that these are the main messages from this module: Applying the basic principles of good communication (show respect, use simple terms, verify correct understanding, address concerns, and enable involvement) ensures the main messages will be understood by teachers, parents and girls Using Triple “A” (Advise, Alert and Arrange) facilitates health workers to correctly convey the correct messages on cervical cancer, its prevention and the correct administration of HPV vaccine 18

End of module for your attention! Thank you This is the end of this module, thank you for your attention!

References Comprehensive cervical cancer prevention and control: a healthier future for girls and women. Guidance Note. WHO 2014 HPV vaccine introduction into national immunization programmes: Information for programme managers and health workers. WHO 2014 Further info: http://www.who.int/nuvi/hpv/resources/en/index.html