# Health System Determinants of Delivery and Uptake of HPV Vaccination Services Among Involuntary Migrant Populations: A Qualitative Systematic Review

## TL;DR

This study reviews how health systems affect HPV vaccination delivery and uptake among involuntary migrants, highlighting barriers and solutions for improving vaccine equity.

## Contribution

The paper introduces a qualitative systematic review focusing on health system determinants of HPV vaccination for involuntary migrants, a previously under-prioritized group.

## Key findings

- Adaptation of immunisation policies and targeted interventions improve vaccine delivery for involuntary migrants.
- Legal status and culturally appropriate messaging significantly influence vaccine uptake among involuntary migrants.
- Fragile health systems in crisis settings hinder prioritization of non-outbreak-related vaccination programs.

## Abstract

Background: Migrant populations are commonly under-immunised relative to general populations in host countries. The evidence base on routine vaccination among migrant children suggests that higher priority is given to infants and younger children compared to adolescents. Though migrants are often classified as a homogenous group, different sub-populations of migrants exist, including voluntary migrants who choose to move and involuntary migrants forcibly displaced by humanitarian crises. The human papillomavirus (HPV) vaccine, a relatively recent addition to global routine immunisation schedules for adolescents, is a useful proxy for understanding vaccine equity for this under-prioritised group. This qualitative systematic review explores health system determinants of delivery and uptake of HPV vaccination services among involuntary migrants. Methods: A literature search was conducted across ten electronic databases. An analytical framework tailored to the migrant context aided in capturing the complexity and magnitude of systemic factors that determine vaccine delivery and uptake among involuntary migrants. Of the 676 records retrieved, 27 studies were included in this review. Results: Key determinants of vaccine delivery include adaptation of immunisation policies for migrant inclusiveness, implementation of migrant-targeted interventions, health provider recommendations, electronic health records, and free vaccines. Uptake determinants include access dependent on legal status, awareness-related determinants akin to culturally appropriate health messaging, and acceptance-related determinants associated with sociocultural beliefs, misinformation, and distrust. Conclusions: Prioritising vaccination programmes linked with non-outbreak-related diseases is challenging in the disruptive context of humanitarian crises given fragile health systems, limited resources, loss of health infrastructure and deployment of health personnel to emergency care. We strongly advocate for global actors at all health systems levels to actively reform national HPV vaccination programmes to enhance inclusivity of adolescent girls in crises settings or resettled in host countries.