Creating Demand for the HPV Vaccine through Girl-Centred Communications

Through a combination of entertainment-education-based media, the partnership aimed to build greater knowledge about cervical cancer and trust in the HPV vaccine and to encourage girls to actively protect their health. The project began with the conviction that, without an accurate understanding of adolescent girls' realities - from their own perspectives - solutions designed to support them would be irrelevant or ineffective. Thus, organisers turned to TEGAs (Technology Enabled Brand Ambassadors), girls aged 18-24 who are trained as researchers by Girl Effect. The TEGAs use Girl Effect's mobile research application to collect insights into the lives of their peers through conversation - providing girls with what is meant to be a safe space to share their authentic views, fears, and hopes. Data collected through the TEGA network in each country played an essential part in the creation of girl-led content that was meant to be authentic and relatable. These data, for example, illuminated the barriers girls and their parents face in understanding cervical cancer and accessing the HPV vaccine, and how best to reach these audiences with media.

Girl Effect's media is designed to communicate factual information in a fun and digestible way, building the knowledge and confidence girls need to make active choices in their lives. Gavi and Girl Effect used an integrated approach by developing content for girls that reflects their world holistically. This meant including storylines in the content not only about the HPV vaccine, but about health and the other issues girls face, such as menstrual health management, contraception, HIV, early marriage, gender-based violence, and education. By embedding HPV content within this larger offering, the aim was to encourage girls to not only obtain the HPV vaccine but also to talk to their peers about their decisions and, more broadly, to act with agency in their pursuit of health. Some examples of media content produced through the project include:

• The radio drama for Tujibebe, Girl Effect's brand in Tanzania, used girl-to-girl conversations as a way to help build awareness, knowledge and attitudes towards the HPV vaccine.
• One storyline in the TV drama for Girl Effect's brand Yegna in Ethiopia showed a loved character dying from cervical cancer and used it as an opportunity to explain how to prevent the disease. Building in the drama of the consequence of the disease was a strategy to help girls see the relevance of the vaccine to them. Another storyline showed that the HPV vaccine is going to be rolled out in school, sparking debate amongst girls and boys about what it is, its benefits, and its potential side effects. A central girl character persuaded her resistant mother she should get the vaccine, using facts.
• Trusted "Aunty" figures in Girl Effect's magazines and radio talkshows (e.g., in Rwanda) provided girls with HPV vaccine information in a way that is meant to be credible and authoritative.
• For Girl Effect's brand Zathu in Malawi, framing health messaging in the context of broader life priorities in its radio drama and magazine was designed to catch girls' attention and prompt action. Music also helped build appeal and reinforce key messages.

In all four countries, Gavi and Girl Effect proactively engaged with the Ministry of Health to build government capacity to use girl-centred approaches for addressing vaccine myths and generating informed demand for HPV vaccination. For example, organisers worked closely with the Ministry of Health in Tanzania and its HPV taskforce, conducting research for them to identify reasons for low uptake of the HPV vaccine and potential solutions. They then recommended how the Ministry of Health's five-year communications strategy might be adjusted to reflect research findings. Media products included, among others, an HPV section in an existing magazine, which was distributed to girls and teachers, and a 3-minute film with music to help build awareness of the HPV vaccine and bust myths about it. The Ministry of Health plans to continue to use a radio and social media campaign created by Girl Effect Tanzania beyond the partnership.

Based on learnings from the partnership, organisers launched the "Girl Focus Toolkit" in 2020 (available at Related Summaries, below). The toolkit aims to support Ministries of Health and other partners in delivering HPV immunisation programmes, providing a resource that will live on beyond this partnership. It includes a set of creative and strategic resources that aim to encourage and enable others to develop their own girl-focused approach to HPV vaccine communications.

Based on this experience, the Ministry of Health in Rwanda requested a new extended partnership with Gavi and Girl Effect ("Rwanda Bridge") to understand gender-based barriers to routine immunisation and to develop girl-centred communications to address these.

Adolescent Girls, Immunisation and Vaccines, Health

Partnership rationale:
Unlike other vaccines, the HPV vaccine is administered to girls during adolescence, and is often their first health intervention since childhood. As such, the HPV vaccine is an opportunity to teach girls about the benefits not only of vaccines, but also of other health interventions, at a crucial time in their lives. This can help set them on a path to adopting positive, health-seeking behaviours. However, negative attitudes and social norms often prevent girls from accessing the HPV vaccine, even when it is available. The barriers girls face to accessing the vaccine include:

• considering health services as not "for them";
• worrying that the HPV vaccine will make them infertile;
• feeling uncomfortable talking about their health; and
• thinking that cervical cancer only happens to middle-aged women.

Impact:
A combination of large- and small-scale studies across each country looked at the impact and reach of different components of the branded media ecosystem. Example findings include (see the document available at the Source section below for more details):

• The media products raised awareness of cervical cancer and the HPV vaccine. For example, 9-year-old girls who read the Zathu magazine were 2.3 times more likely to be aware of the HPV vaccine than those who hadn't. In Ethiopia, girls who viewed the Yegna TV drama were 1.6 times more likely to be aware of the HPV vaccine.
• Girls were less likely to believe myths about cervical cancer and have correct knowledge about the vaccine. In Ethiopia, girls aged 13-15 who watched the Yegna TV drama were more likely to know "a lot" or "some things" about cervical cancer (53% vs. 30%) and were more likely to believe that the vaccine will not stop girls from giving birth (69% vs. 64%). In Malawi, girls aged 9 who read the Zathu magazine thought that the HPV vaccine will not stop girls from giving birth (vs. 32% of those who did not read the magazine, who thought it would).
• Girls were more likely to discuss the HPV vaccine. For example, in Ethiopia, girls aged 13-15 who had seen the Yegna TV drama were more likely to have spoken to someone about the HPV vaccine (61% vs. 37%). In Malawi, girls aged 9 who read the Zathu magazine were more likely to have spoken to someone else about the HPV vaccine (46% vs. 32%), and girls were more likely to have spoken to someone else about their general health (37% vs. 28%).
• There was an increased intention and/or decision to receive the HPV vaccine. For example, 13-15 year old girls who had seen the Yegna TV drama were 60% more likely to intend to have the vaccine than those girls who hadn't. In Ethiopia, girls who had watched the Yegna TV drama had greater intention to vaccinate than those who had not (70% vs. 43%). In Malawi, girls who read the Zathu magazine were more likely to have had their first dose than those who had not read it (20% difference); 9-year-old girls in that country who had consumed Zathu content were 32% more likely to have the vaccine. And in Ethiopia, girls who were exposed to the Yegna talk show campaign (on TV, radio, and social media) were more likely to have received the second dose of the HPV vaccine in 2021 (83% vs. 78%).

Alongside quantitative studies, the partnership engaged girls in the design, testing, and evaluation of the content and products in an effort to ensure the messages were engaging, relevant, and meaningful.

Lessons learned for future partnerships include:

• Ensure the Ministry of Health and HPV technical working group are involved in programme design from the beginning as well as during the partnership.
• Build on the partnership model to be an integrated part of overall partnership strategy: Once vaccines are launched, there is scope to reach under-immunised girls more effectively by understanding the barriers they face and building further partnerships to reach them.
• Go beyond gender sensitivity by working closely with partners to transform key gender inequalities, to be measured by the impact on all relevant groups (e.g., including boys).
• Agree on indicators that enable regular tracking, and formalise value for money, from the beginning.
• Share lessons learned more broadly - e.g., through regular workshops and webinars.