Recruitment
Participants will be purposively sampled from communities in the district Chongwe in Lusaka province, as Lusaka has the highest incidence of cervical cancer compared to other provinces in Zambia (36) and most research on HPV vaccination hesitancy in Zambia has been conducted there (13, 14, 37). Furthermore, Chongwe was chosen for its rural setting, where community groups have been shown to be most effective (23). Community groups will meet monthly with around 30 members. Thirty villages in the rural district of Chongwe will be matched into 15 pairs and a cluster in each pair randomly allocated into an intervention arm and control arm. The estimated population of Chongwe is 188,091 (38). Each cluster will therefore have an average population of around 6,300 people, which is a similar number to previous studies on community groups (23). Participation in this intervention is voluntary and consent may be withdrawn at any time. While informed consent will be gained from all participants, written informed consent may be difficult in CRCTs where village leaders make decisions collectively on behalf of the group (39). Consent will therefore be gained from key stakeholders during the formative research phase, in case there are difficulties obtaining written consent from individual participants.
Theory of change
Two theories underpin the aim of this intervention to improve HPV vaccination uptake in this population through PLA community groups. Firstly, that an individual’s health behaviours are influenced by their social networks. And secondly, that PLA cycles increase community mobilisation to improve health outcomes. Rooted in behavioural science theories such as Bandura’s (1997) social learning theory and Bronfenbrenner’s (40) Ecological Framework for Human Development, a social ecological approach can be used to better understand health behaviours in the context of vaccinations. The social ecological model suggests that individual’s health behaviours are influenced by the health behaviours of their close social network and wider community members (41). Community groups are thought to allow individuals to collectively engage with these social and community-level influences. This has been witnessed in Zambia, where knowing someone in the community that vaccinated their daughter increased the likelihood that mothers would vaccinate their own daughters (13).
A key theory underlying this intervention is that health outcomes improve when communities are empowered to increase their health literacy, make decisions about resource allocation, and be involved in implementing solutions. PLA is thought to give agency to group members, empower marginalised communities and facilitate community mobilisation to address their own health needs (42). The value of community group PLA is thought to lie in the process of collectively reaching solutions, rather than solely the solutions themselves (21). In this context, PLA community groups are predicted to help communities identify factors which facilitate HPV uptake such as motivation, trust and social support (22) and address barriers such as lack of knowledge (13), concerns and misunderstandings (14), women’s limited decision-making power (15), social norms (15), stigma (17), religious beliefs (33) as well as financial and geographical barriers to access (22, 43).
The capability, opportunity, motivation, behaviour (COM-B) model can help identify, prioritise and better understand enabling factors and barriers to vaccination uptake. The COM-B model is a widely used framework for understanding a variety of health behaviours as a result of the interaction between the factors influencing an individual’s capability, opportunity and motivation to act (44). Extensive research on theories underpinning health behaviours in the context of vaccine uptake has led to the development of a tailored COM-B model recommended as part of the WHO’s (2019) Tailoring Immunisations Program (TIP). The TIP COM-B model expands on the original principles of COM-B so that Capability includes knowledge, skills and physical ability, Opportunity includes vaccine accessibility, affordability and social influences, and Motivation includes attitudes, emotions and beliefs surrounding the vaccine (45).
Stakeholders
Key stakeholders to be engaged in this project include government members (health minister and district government representatives), policymakers, healthcare workers (members of the cervical cancer prevention program in Zambia (CCPPZ) and community health workers), donors and relevant non-governmental organisations (NGO), religious leaders, and most importantly, civil society members including but not limited to mothers, fathers, grandparents and school teachers. These stakeholders have all been shown to influence collective health beliefs and behaviours surrounding the HPV vaccine in Zambia (15). There are several other stakeholders collaborating with the ministry of health to run the CCPPZ, which are not key stakeholders for this intervention but may require engagement throughout the project if necessary. These include the Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka University Teaching Hospital, a partner university in the U.S. (46), as well as the Ministries of Education, Chiefs and Traditional Affairs, Community Development and Social Welfare, Higher Education (9).
Formative research with key stakeholders through semi-structured interviews and focus group discussions will provide valuable insights into the acceptability and feasibility of the proposed intervention and can identify any required adaptations to the implementation process. The stakeholder meetings will allow for the project team to assess the readiness for change and engagement with community leaders. A pilot community group session will also be conducted to assess feasibility, acceptability and identify adaptations as needed. Community leaders will be engaged to lead a gradual introduction of the project into their community during the formative research phase. A sensitisation period such as this has been deemed an important missing component to previous HPV vaccination programs (15, 47–49).
The project will require political support with coordination between the project team, Ministry of Health and district level government members to ensure institutional support, adequate and equitable allocation of resources. This would involve collaborating on a detailed budget distribution plan for the program’s duration (30). Engaging with NGOs which have mutual health agendas has been shown to increase uptake of HPV vaccination (50). The CCPPZ works closely with HIV programs, through which they receive a significant portion of donor funding (46). This project will coordinate with NGOs to ensure funding is maintained and prevent parallel programs interfering with one another. Joining efforts and utilising any ongoing positive social movements can increase community support as well (22).
The community groups will be facilitated by local CCPPZ members. The CCPPZ has an existing network of volunteers who facilitate community-based teaching to increase cervical cancer awareness (46). These facilitators will be recruited and trained in the PLA approach to facilitate the community group meetings. They will be central to the success of the community groups as being members of the local community will increase acceptability and possibly sustainability of the intervention beyond the timeframe of this project. Their knowledge on cervical cancer and the HPV vaccine will allow them to address concerns and misconceptions of the group when needed, in a dynamic and participatory way.
This project aims to serve as a platform for strengthening partnerships between stakeholders in order to make a lasting impact beyond the scope of this project. If successful, this project will work closely with the ministry of health, district governments and the CCPPZ to integrate community groups and the PLA approach into their existing cervical cancer prevention program.