Communication around HPV vaccination for adolescents in low- and middle-income countries: a systematic scoping overview of systematic reviews

Background Human papillomavirus (HPV) infection causes cervical cancer. More than 80% of those diagnosed with cervical cancer live in low- and middle-income countries (LMICs). The World Health Organization recommends vaccination as a public health measure against cervical cancer. Communication interventions are able to change how people think about vaccination and are thus instrumental in addressing vaccine hesitancy. Our aim was to provide a broad scoping overview of the available evidence on communication with adolescents, parents, and other stakeholders around HPV vaccination for adolescents, with a specific focus on LMICs. Methods We conducted a systematic scoping overview of systematic reviews addressing a range of questions regarding communication around HPV vaccination. We considered reviews published between 2007 and 2018 focusing on communication around HPV vaccination and that searched for qualitative or quantitative studies for inclusion. We searched the Epistemonikos database which includes reviews from multiple electronic databases. Two overview authors screened titles and abstracts and examined potentially eligible reviews in full text. Data extraction was performed by one overview author and verified by a second. We assessed the reliability of the included reviews using an adapted version of AMSTAR 2. Results We included twelve reviews in our overview. Four reviews assessed the effectiveness of communication interventions. These interventions intended to inform or educate about HPV and HPV vaccination, such as videos and fact sheets, or to remind or recall, such as text message reminders. Eight reviews assessed factors associated with HPV vaccination uptake, including communication-related factors such as whether the vaccine was recommended by a physician and people’s knowledge regarding the vaccine. Nine reviews searched for studies from LMICs, but most found only a small number of studies from these countries. Conclusions The small number of studies identified from LMICs is of concern as these countries face the largest burden of disease related to HPV. This scoping overview also found and excluded a number of reviews because of important methodological limitations, highlighting the need for future reviews to use appropriate methods. The overview indicates areas in which further primary studies are needed on HPV vaccination communication in LMICs. Systematic review registration Open Science Framework https://osf.io/agzb4/ Electronic supplementary material The online version of this article (10.1186/s13643-019-1100-y) contains supplementary material, which is available to authorized users.


Yes
The assessment of methodological limitations is not explained per individual study, but is used and explained overall. 10. Did the review authors report on the sources of funding for the studies included in the review?

No
Minor limitation.
11. If a synthesis was performed did the review authors use appropriate methods to combine the results of individual studies?
Yes 12. If synthesis was performed, did the review authors assess the potential impact of the methodological limitations / RoB in individual studies on the results of the evidence synthesis?
Yes 13. Did the review authors account for methodological limitations / RoB in individual studies when interpreting/ discussing the results of the review? Yes 14. Did the review authors provide a satisfactory explanation for, and discussion of, any heterogeneity observed in the results of the review?
(Omit for QES and for some reviews of survey data)

No
Minor limitation. 15. If they performed quantitative synthesis did the review authors carry out an adequate investigation of publication bias (small study bias) and discuss its likely impact on the results of the review? 14. Did the review authors provide a satisfactory explanation for, and discussion of, any heterogeneity observed in the results of the review?
(Omit for QES and for some reviews of survey data)

No
Minor limitation. 15. If they performed quantitative synthesis did the review authors carry out an adequate investigation of publication bias (small study bias) and discuss its likely impact on the results of the review?

No
Minor limitation. 16. Did the review authors report any potential sources of conflict of interest, including any funding they received for conducting the review?

No
Minor limitation.
Overall assessment Important limitations. Explanation of overall assessment Twelve minor limitations. 5. Did the review authors perform study selection in duplicate? Yes 6. Did the review authors perform data extraction in duplicate? Yes 7. Did the review authors provide a list of excluded studies and justify the exclusions?
For Partial Yes: provided a list of all potentially relevant studies that were read in full-text form but excluded from the review 11. If a synthesis was performed did the review authors use appropriate methods to combine the results of individual studies?
No Minor limitation.
12. If synthesis was performed, did the review authors assess the potential impact of the methodological limitations / RoB in individual studies on the results of the evidence synthesis?
No Minor limitation.
13. Did the review authors account for methodological limitations / RoB in individual studies when interpreting/ discussing the results of the review? Yes 14. Did the review authors provide a satisfactory explanation for, and discussion of, any heterogeneity observed in the results of the review?
(Omit for QES and for some reviews of survey data)

No
Minor limitation. 15. If they performed quantitative synthesis did the review authors carry out an adequate investigation of publication bias (small study bias) and discuss its likely impact on the results of the review?
(Omit for QES) Yes 16. Did the review authors report any potential sources of conflict of interest, including any funding they received for conducting the review?
Yes None declared.

Overall assessment Minor limitations. Explanation of overall assessment
One major limitation. Six minor limitations. 5. Did the review authors perform study selection in duplicate? Yes 6. Did the review authors perform data extraction in duplicate? No Minor limitation. 7. Did the review authors provide a list of excluded studies and justify the exclusions?
For Partial Yes: provided a list of all potentially relevant studies that were read in full-text form but excluded from the review 14. Did the review authors provide a satisfactory explanation for, and discussion of, any heterogeneity observed in the results of the review?
(Omit for QES and for some reviews of survey data)

No
Minor limitation. 15. If they performed quantitative synthesis did the review authors carry out an adequate investigation of publication bias (small study bias) and discuss its likely impact on the results of the review?

No
Minor limitation. 16. Did the review authors report any potential sources of conflict of interest, including any funding they received for conducting the review?

Yes
Overall assessment Important limitations. Explanation of overall assessment One major limitation. Ten minor limitations.
Yes 2. Did the report of the review contain an explicit statement that the review methods were established prior to the conduct of the review and did the report justify any significant deviations from the protocol? 14. Did the review authors provide a satisfactory explanation for, and discussion of, any heterogeneity observed in the results of the review?
(Omit for QES and for some reviews of survey data) Yes 15. If they performed quantitative synthesis did the review authors carry out an adequate investigation of publication bias (small study bias) and discuss its likely impact on the results of the review?

No
Minor limitation. 16. Did the review authors report any potential sources of conflict of interest, including any funding they received for conducting the review?
No. Minor limitation. Reported as 'none' in the protocol, but not mentioned in the review.
Overall assessment Important limitations. Explanation of overall assessment One major limitation. Nine minor limitations. 14. Did the review authors provide a satisfactory explanation for, and discussion of, any heterogeneity observed in the results of the review?
(Omit for QES and for some reviews of survey data)

No
Minor limitation.
15. If they performed quantitative synthesis did the review authors carry out an adequate investigation of publication bias (small study bias) and discuss its likely impact on the results of the review?

No
Minor limitation. 16. Did the review authors report any potential sources of conflict of interest, including any funding they received for conducting the review?

No
Minor limitation.
Overall assessment Important limitations. Explanation of overall assessment One major limitation. Eleven minor limitations.
Criteria for assessing reviews (adapted from AMSTAR) Review  15. If they performed quantitative synthesis did the review authors carry out an adequate investigation of publication bias (small study bias) and discuss its likely impact on the results of the review?

No
Minor limitation. 16. Did the review authors report any potential sources of conflict of interest, including any funding they received for conducting the review?

Yes
Overall assessment Important limitations. Explanation of overall assessment One major limitation. Seven minor limitations.
Criteria for assessing reviews (adapted from AMSTAR) Review  Yes 2. Did the report of the review contain an explicit statement that the review methods were established prior to the conduct of the review and did the report justify any significant deviations from the protocol?

No
Searches in Prospero and BMC Systematic Reviews yielded no results. No relevant statement found. Minor limitation. 3. Did the review authors explain their selection of the study designs for inclusion in the review?

Yes
No limit was placed on study design; however, included articles were required to report original data (i.e. not reviews, editorials or commentary). 14. Did the review authors provide a satisfactory explanation for, and discussion of, any heterogeneity observed in the results of the review?
(Omit for QES and for some reviews of survey data)

No
Minor limitation.
15. If they performed quantitative synthesis did the review authors carry out an adequate investigation of publication bias (small study bias) and discuss its likely impact on the results of the review?

No
Mentioned as a possible limitation, but not investigated. Minor limitation. 16. Did the review authors report any potential sources of conflict of interest, including any funding they received for conducting the review?

Yes
Overall assessment Important limitations. Explanation of overall assessment One major limitation. Nine minor limitations.
Criteria for assessing reviews (adapted from AMSTAR) Review  2. Did the report of the review contain an explicit statement that the review methods were established prior to the conduct of the review and did the report justify any significant deviations from the protocol? Yes 2. Did the report of the review contain an explicit statement that the review methods were established prior to the conduct of the review and did the report justify any significant deviations from the protocol?

No
Not found. Minor limitation.
3. Did the review authors explain their selection of the study designs for inclusion in the review? 15. If they performed quantitative synthesis did the review authors carry out an adequate investigation of publication bias (small study bias) and discuss its likely impact on the results of the review?
(Omit for QES) Not applicable. 16. Did the review authors report any potential sources of conflict of interest, including any funding they received for conducting the review? Yes 2. Did the report of the review contain an explicit statement that the review methods were established prior to the conduct of the review and did the report justify any significant deviations from the protocol?

No
Searches in Prospero and BMC Systematic Reviews yielded no results. No relevant statement found. Minor limitation. 3. Did the review authors explain their selection of the study designs for inclusion in the review? 14. Did the review authors provide a satisfactory explanation for, and discussion of, any heterogeneity observed in the results of the review?
(Omit for QES and for some reviews of survey data) Yes 15. If they performed quantitative synthesis did the review authors carry out an adequate investigation of publication bias (small study bias) and discuss its likely impact on the results of the review?

No
Minor limitation. 16. Did the review authors report any potential sources of conflict of interest, including any funding they received for conducting the review?

No
Minor limitation.

Overall assessment Important limitations. Explanation of overall assessment
One major limitation. Nine minor limitations.
Criteria for assessing reviews (adapted from AMSTAR) Review   14. Did the review authors provide a satisfactory explanation for, and discussion of, any heterogeneity observed in the results of the review?
(Omit for QES and for some reviews of survey data)

No
Minor limitation.
15. If they performed quantitative synthesis did the review authors carry out an adequate investigation of publication bias (small study bias) and discuss its likely impact on the results of the review?
(Omit for QES) Not applicable. Not performed. 16. Did the review authors report any potential sources of conflict of interest, including any funding they received for conducting the review?
Yes Not funded.
Overall assessment Important limitations. Explanation of overall assessment One major limitation. Eight minor limitations.
Criteria for assessing reviews (adapted from AMSTAR) Review  15. If they performed quantitative synthesis did the review authors carry out an adequate investigation of publication bias (small study bias) and discuss its likely impact on the results of the review?
(Omit for QES) Not applicable. Not performed. 16. Did the review authors report any potential sources of conflict of interest, including any funding they received for conducting the review?
Yes "This study was supported by a career development award from the National Cancer Institute (K22 CA186979). The funder did not play a role in study design, data analysis, report writing, or the decision to submit the article for publication." Overall assessment Important limitations. Explanation of overall assessment One major limitation. Eight minor limitations.
Criteria for assessing reviews (adapted from AMSTAR) Review  14. Did the review authors provide a satisfactory explanation for, and discussion of, any heterogeneity observed in the results of the review?
(Omit for QES and for some reviews of survey data)

Yes
Satisfactory explanation for heterogeneity of populations.
15. If they performed quantitative synthesis did the review authors carry out an adequate investigation of publication bias (small study bias) and discuss its likely impact on the results of the review?
(Omit for QES) Not applicable. Not performed. 16. Did the review authors report any potential sources of conflict of interest, including any funding they received for conducting the review?
Yes "This review is part of the multi-method HPV Core 14. Did the review authors provide a satisfactory explanation for, and discussion of, any heterogeneity observed in the results of the review?
(Omit for QES and for some reviews of survey data)

No
No satisfactory explanation for the heterogeneity observed in some of the results. Minor limitation.
15. If they performed quantitative synthesis did the review authors carry out an adequate investigation of publication bias (small study bias) and discuss its likely impact on the results of the review?
(Omit for QES) Not applicable. Not performed.
16. Did the review authors report any potential sources of conflict of interest, including any funding they received for conducting the review?
Yes "Conflict of Interest of Disclosures: None reported." Overall assessment Important limitations. Explanation of overall assessment Two major limitations. Nine minor limitations.
Criteria for assessing reviews (adapted from AMSTAR) Review  14. Did the review authors provide a satisfactory explanation for, and discussion of, any heterogeneity observed in the results of the review?
(Omit for QES and for some reviews of survey data)

No
Minor limitation.
15. If they performed quantitative synthesis did the review authors carry out an adequate investigation of publication bias (small study bias) and discuss its likely impact on the results of the review?
(Omit for QES) Not applicable. Not performed. 16. Did the review authors report any potential sources of conflict of interest, including any funding they received for conducting the review?

No
Minor limitation.

Overall assessment Important limitations. Explanation of overall assessment One major limitation. Eleven minor limitations.
Criteria for assessing reviews (adapted from AMSTAR) Review  Yes 2. Did the report of the review contain an explicit statement that the review methods were established prior to the conduct of the review and did the report justify any significant deviations from the protocol?

No
Searches in Prospero and BMC Systematic Reviews yielded no results. No relevant statement found. Minor limitation. 3. Did the review authors explain their selection of the study designs for inclusion in the review?

Yes
No selection of study design.

Did the review authors use a comprehensive literature search strategy?
For Partial Yes (all the following): searched at least 2 databases (relevant to research question) provided key word and/or search strategy justified publication restrictions (e.g. language) For Yes, should also have (all the following): 14. Did the review authors provide a satisfactory explanation for, and discussion of, any heterogeneity observed in the results of the review?
(Omit for QES and for some reviews of survey data)

Yes
No major heterogeneity observed.
15. If they performed quantitative synthesis did the review authors carry out an adequate investigation of publication bias (small study bias) and discuss its likely impact on the results of the review?
(Omit for QES) Not applicable. Not performed. 16. Did the review authors report any potential sources of conflict of interest, including any funding they received for conducting the review?

Yes
This publication is based on research funded by the Bill & Melinda Gates Foundation.

Overall assessment Important limitations. Explanation of overall assessment One major limitation. Nine minor limitations.
Criteria for assessing reviews (adapted from AMSTAR) Review  14. Did the review authors provide a satisfactory explanation for, and discussion of, any heterogeneity observed in the results of the review?
(Omit for QES and for some reviews of survey data)

No
Minor limitation.
15. If they performed quantitative synthesis did the review authors carry out an adequate investigation of publication bias (small study bias) and discuss its likely impact on the results of the review?
(Omit for QES) Not applicable. 16. Did the review authors report any potential sources of conflict of interest, including any funding they received for conducting the review? (Omit for QES and for some reviews of survey data) Yes 15. If they performed quantitative synthesis did the review authors carry out an adequate investigation of publication bias (small study bias) and discuss its likely impact on the results of the review?
(Omit for QES) Not applicable. 16. Did the review authors report any potential sources of conflict of interest, including any funding they received for conducting the review?

No
Minor limitation.

Overall assessment Important limitations. Explanation of overall assessment Eight minor limitations.
Criteria for assessing reviews (adapted from AMSTAR) Review  Yes 2. Did the report of the review contain an explicit statement that the review methods were established prior to the conduct of the review and did the report justify any significant deviations from the protocol?

No
Searches in Prospero and BMC Systematic Reviews yielded no results. No relevant statement found. Minor limitation. 3. Did the review authors explain their selection of the study designs for inclusion in the review?

Yes
No selection of study design made.

Did the review authors use a comprehensive literature search strategy?
For Partial Yes (all the following): searched at least 2 databases (relevant to research question) provided key word and/or search strategy justified publication restrictions (e.g. language) For Yes, should also have (all the following): 14. Did the review authors provide a satisfactory explanation for, and discussion of, any heterogeneity observed in the results of the review?
(Omit for QES and for some reviews of survey data)

No
No satisfactory explanation made for the heterogeneity observed in the results. Minor limitation.
15. If they performed quantitative synthesis did the review authors carry out an adequate investigation of publication bias (small study bias) and discuss its likely impact on the results of the review?
(Omit for QES) Not applicable. Not performed due to heterogeneity of settings and sample characteristics. 16. Did the review authors report any potential sources of conflict of interest, including any funding they received for conducting the review?
No "The authors have no funding support to report. "

Overall assessment Minor limitations. Explanation of overall assessment Eight minor limitations.
Criteria for assessing reviews (adapted from AMSTAR) Review  Yes 2. Did the report of the review contain an explicit statement that the review methods were established prior to the conduct of the review and did the report justify any significant deviations from the protocol?

No
Not mentioned and no protocol to be found in Prospero or BMC Systematic Reviews. Minor limitation. 3. Did the review authors explain their selection of the study designs for inclusion in the review?

No
Reasoning not explained. Minor limitation.

Did the review authors use a comprehensive literature search strategy?
For Partial Yes (all the following): searched at least 2 databases (relevant to research question) provided key word and/or search strategy justified publication restrictions (e.g. language) For Yes, should also have (all the following): 14. Did the review authors provide a satisfactory explanation for, and discussion of, any heterogeneity observed in the results of the review?
(Omit for QES and for some reviews of survey data)

Yes
Heterogeneity of the population and the inconsistent variables mentioned as a reason for not being able to pool the results for statistical significance.
15. If they performed quantitative synthesis did the review authors carry out an adequate investigation of publication bias (small study bias) and discuss its likely impact on the results of the review?

No
Minor limitation. 16. Did the review authors report any potential sources of conflict of interest, including any funding they received for conducting the review?

Overall assessment
Does not meet threshold.

Explanation of overall assessment Two major limitations. Seven minor limitations.
Criteria for assessing reviews (adapted from AMSTAR) Review  15. If they performed quantitative synthesis did the review authors carry out an adequate investigation of publication bias (small study bias) and discuss its likely impact on the results of the review?
(Omit for QES) Not applicable. Not performed. 16. Did the review authors report any potential sources of conflict of interest, including any funding they received for conducting the review?

No
Minor limitation.

Overall assessment Important limitations. Explanation of overall assessment Two major limitations. Eight minor limitations.
Criteria for assessing reviews (adapted from AMSTAR) Review  14. Did the review authors provide a satisfactory explanation for, and discussion of, any heterogeneity observed in the results of the review?
(Omit for QES and for some reviews of survey data)

No
Formal meta-analysis was not performed because of heterogeneity across studies in outcomes measures. No heterogeneity in results explained. Minor limitation. 15. If they performed quantitative synthesis did the review authors carry out an adequate investigation of publication bias (small study bias) and discuss its likely impact on the results of the review?
Not performed. 16. Did the review authors report any potential sources of conflict of interest, including any funding they received for conducting the review?
Yes "The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and the decision to submit the manuscript for publication. This work was supported by grant T32 AI007210 from the National Institutes of Health (Dr Hansen)." Overall assessment Important limitations. Explanation of overall assessment One major limitation. Nine minor limitations.
Criteria for assessing reviews (adapted from AMSTAR) Review  14. Did the review authors provide a satisfactory explanation for, and discussion of, any heterogeneity observed in the results of the review?
(Omit for QES and for some reviews of survey data)

No
Minor limitation.
15. If they performed quantitative synthesis did the review authors carry out an adequate investigation of publication bias (small study bias) and discuss its likely impact on the results of the review?
(Omit for QES) Not applicable. Not performed. 16. Did the review authors report any potential sources of conflict of interest, including any funding they received for conducting the review?
No "Funding: The authors have no support or funding to report." Overall assessment Important limitations. Explanation of overall assessment One major limitation. Nine minor limitations.
Criteria for assessing reviews (adapted from AMSTAR) Review  Yes 2. Did the report of the review contain an explicit statement that the review methods were established prior to the conduct of the review and did the report justify any significant deviations from the protocol?

No
Searches in Prospero and BMC Systematic Reviews yielded no results. No relevant statement found. Minor limitation. 3. Did the review authors explain their selection of the study designs for inclusion in the review?

Yes
No selection of study designs needing explanation.

Did the review authors use a comprehensive literature search strategy?
For Partial Yes (all the following): searched at least 2 databases (relevant to research question) provided key word and/or search strategy justified publication restrictions (e.g. language) For Yes, should also have (all the following): 11. If a synthesis was performed did the review authors use appropriate methods to combine the results of individual studies?
Yes 12. If synthesis was performed, did the review authors assess the potential impact of the methodological limitations / RoB in individual studies on the results of the evidence synthesis?
Yes 13. Did the review authors account for methodological limitations / RoB in individual studies when interpreting/ discussing the results of the review? Yes 14. Did the review authors provide a satisfactory explanation for, and discussion of, any heterogeneity observed in the results of the review?
(Omit for QES and for some reviews of survey data) Yes 15. If they performed quantitative synthesis did the review authors carry out an adequate investigation of publication bias (small study bias) and discuss its likely impact on the results of the review?
(Omit for QES) Not applicable. 16. Did the review authors report any potential sources of conflict of interest, including any funding they received for conducting the review?

No
Overall assessment Minor limitations. Explanation of overall assessment Six minor limitations.
6. Did the review authors perform data extraction in duplicate? Yes 7. Did the review authors provide a list of excluded studies and justify the exclusions?
For Partial Yes: provided a list of all potentially relevant studies that were read in full-text form but excluded from the review 15. If they performed quantitative synthesis did the review authors carry out an adequate investigation of publication bias (small study bias) and discuss its likely impact on the results of the review?
(Omit for QES) Not applicable. Heterogeneity among studies precluded metaanalysis. 16. Did the review authors report any potential sources of conflict of interest, including any funding they received for conducting the review?  15. If they performed quantitative synthesis did the review authors carry out an adequate investigation of publication bias (small study bias) and discuss its likely impact on the results of the review?

No
Minor limitation. 16. Did the review authors report any potential sources of conflict of interest, including any funding they received for conducting the review?

Yes
Overall assessment Important limitations. Explanation of overall assessment One major limitation. Nine minor limitations.
Criteria for assessing reviews (adapted from AMSTAR) Review

No
No key word or search strategy provided. Major limitation.