Bixby Center Lecture April 16, 2019 Adriana Baban Babes-Bolyai University, Dept. of Psychology Cluj-Napoca, Romania

1. Understanding HPV vaccine hesitancy
from a cultural and social perspective:
Romania case study
Adriana Baban
Babes-Bolyai University, Dept. of Psychology
Cluj-Napoca, Romania
April 2019, UCLA

2. Presentation outline
 Background: HPV vaccination in Romania
 Findings of empirical studies:
1. Parents’ perspectives on HPV vaccines
2. HPV vaccine representation on online discussion forums
3. Media coverage of HPV vaccination
4. Health professionals’ views on HPV vaccines
5. Determinants of HPV vaccine acceptability in young
adults
6. Message framing interventions to increase HPV vaccine
acceptability
 General conclusions
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3. Mortality Rates from Cervical Cancer in Europe
Romania
9.55
Bulgaria
6.7
France
Germany
Netherlands
Portugal
Sweden
United Kingdom
EU members
before 2004
Per 100,000 women, ages 0- 64; Health for All Database (2012)

4. Background
 For the last 30+ years, Romania has had the highest
cervical cancer mortality in Europe, with rates ~ 6 times
higher than the average of EU
Prevention of cervical cancer
 Through screening: secondary prevention
 Papanicolaou smear (PAP)
 Romania did not have a population based screening
program.
 Through vaccination: primary prevention
 HPV vaccine (2006)
 HPV vaccination - will achieve the desired reductions in
cervical cancer rates only if coverage is high 4

6. Background
 HPV vaccination introduction in RO:
 November 2008 – launch of vaccination campaign;
 Vaccines fully covered by national health authorities;
 Target group 10-11-year old girls
 Vaccines were delivered mostly through school-based
programmes
 Parental written consent
Campaign was unsuccessful, uptake rate was 2.5 % from
eligible girl’s groups
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7. Background
 November 2009: re-launching of the vaccination campaign,
target age 12-14
 delivered through public health/primary care doctors, school
health services, public hospitals
 Parental verbal consent
 The attendance rate still very low (~ 5%)
 2010: catch-up programme included target age group:
12- 24 (delivered through public health/primary care doctors,
school health services, public hospitals; attendance rate
almost the same as previous, a little bit higher among
university students).
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8. Background
 The campaign was stopped (low acceptance rates)
 The remained vaccines doses have expired
 Suboptimal communication strategy & implementation may
have negatively affected HPV vaccination campaign
 No national HPV vaccination program; still no standard
recommendation about the vaccination
 HPV vaccine is often missing also from the pharmacies
 There are no recommendations for vaccinating boys.
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9. Aim:
 To better understand this growing challenge of HPV vaccine refusal
despite availability of vaccination services
 Participants: different actors (triangulation perspectives)
 Mixed methods approach
Funders:
 USA, National Council on Eurasian & East European Research Social, Political
and Gendered Dimensions of Preventive Technologies in Bulgaria and Romania:
The case of HPV vaccine implementation
 ECDC, Stockholm Vaccine hesitancy among health care workers
 National Council of Research Media discussions surrounding HPV vaccines
 Centre de Recherche du Centre hospitalier universitaire de Sherbrooke, Québec, Canada;
 EC: H2020

10. Understanding the reasons why Romanian mothers
decline HPV vaccination for their daughters
Objectives
 The study aimed to explore Romanian mothers’
perceptions & attitudes towards HPV vaccine
Method
 3 focus groups (n = 21) and 9 semi-structured individual
interviews with women aged 30–50
 Thematic analysis was applied (Brown and Clarke, 2006)
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12. Findings
 All participants have refused vaccination of their daughters
Emerged themes
 The risky vaccine
 Vaccine as experiment
 The vaccination campaign as the reflection on an ineffective
health care system
 Partnership between parents and health professionals in decision
making
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13. The risky vaccine
 Fear about short and long term side effects:
- paralyze; infection; risk of getting cancer in the future; death; future
infertility:
“I would destroy her femininity….”
“She will not be a woman anymore”
“They have to give birth to the next generations…why to take this risk?”
 Fear of assuming responsibility of possible negative effects
“I would vaccinate my self, but not my daughter, she is too young”
“Who will take the responsibility for the possible negative effects?“
“When they are older they can decide for themselves.”

14. Vaccine as experiment
 Lack of long term data showing the effectiveness; suspicion: the
gratuity of the vaccine; hidden medical interests; serving the interest
of pharmaceutical companies; conspiracy theory; a strategy to reduce
the world population;
“..they can do and say anything in order to sell their products for huge profit”.
“The winner of the campaign will be pharmaceutical companies and the
losers will be our daughters”
“They are using our children as “guinea pigs” for their experiment”
“If somebody offers you something for free, you are sceptical. You ask
yourself why?....”.

15. The vaccination campaign: reflection of an ineffective
health care system
 Distrust in health care system and health professionals; the lack
of information or contradictory information provided;
 Mothers felt the vaccine was “pushed” on them with lack of respect
for the opinion of parents; confusion and mistrust; offended, anger
“Being typical of how the Romanian health system works”;
“Some of the doctors who advertised the vaccine in schools
were a bit too enthusiastic about it”;
“A doctor told me she wouldn’t vaccinate her daughters”;

16. Partnership between parents and health professionals in
decision making
 Need for clear and honest information “from trustworthy doctors
who are not in service for pharmaceutical companies..” and
believe that future campaigns should be conducted over a
longer period of time.
 The influence of “other mothers” was considered important:
“only mothers would understand your fears”
 Partnership between parents and health professionals in
decision making based on trust, respect

17. The main reasons of Romanian mothers for
declining the HPV vaccine for their daughters are:
 Lack of information and knowledge
 Low perceived risk of HPV infection
 Age-related concerns
 Short and long term side effects
 Responsibility for the vaccine’s consequences
 Lack of trust in the medical system

18. HPV Vaccine Representations on Online Discussion
Forums in Romania
Aim, and Method
 To explore the public’s constructions of the HPV vaccine as
they were expressed on Internet discussion forums.
 20 forums, with a total sample size of 2,240 comments
 Thematic analysis (Braun & Clark, 2006) with a focus on
language, informed by a discourse analytic approach
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20. Findings
Three categories of active forum users:
 Information-seekers—to vaccinate or not to vaccinate?
“should I believe doctors or rumors”?
“ I don’t know what to do?”
 Supporters - how is the vaccine constructed as beneficial?
science -oriented people endorse vaccination and
evidence-based medicine in general; “Helpful discovery”;
“the normal thing to do”; “to fight against those irrational
people”; “to fight against obscurantism and primitivism”;
 Opponents—how is the vaccine constructed as harmful? 20

21. Dangerous Vaccine - vaccine “more dangerous than the disease
itself”; concern over side effects, mortality, insufficient testing
and unknown long-term effects; warnings against vaccine use.
“Have you seen the recent case in England concerning the girl
who died only a few hours post vaccination?
“Do not vaccinate your daughters OR you will risk their lives!
Many girls died, became paralyzed or they ended up so ill they
need to take tons of medicines for the rest of their lives. Could
you live with the guilt of causing permanent harm to your child?
”This vaccine was banned in America, Canada and Austria
because it has caused 25 deaths!!”.
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22. Conspiracy Theories
“Sterilizing vaccine”, vaccine as a means to reduce the
population, fears of being used as “guinea pigs”; genocide;
“Masonic vaccine”
“Some guys out there consider we are too many on this
earth!…They want us dead.”
“This vaccine “helps” girls so that they will not be able to
have children. Ministry of health has become the Ministry
of sterilization
“We have become the guinea pigs for the entire world!”
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23. Lack of trust and discontent with the national
health system
 The trustworthiness of pharmaceutical companies, Government and
doctors is contested
“Do you know that Hitler and Bormann invested in Merck company?”
“Suddenly the Health Minister was so preoccupied with our best interest! the
money they’ve received had nothing to do with them pushing the vaccine.”
“Cancer produces money; they play with your perceptions and fears”.
“Tell me who funds the study and I’ll tell you what the conclusions are.”
“I find suspicious the rush with which the vaccine was launched in a country
where the health system does nothing for people”.
“Every nation make fun of us; they refused the vaccine, that’s why they sent
it here”

24. HPV Vaccine as “an Injectable Condom”
 vaccine as promoting promiscuity in girls
“The Ministry of Sin sends the message that by getting vaccinated
girls can sin as long as they want”.
“Do I vaccinate my daughter and give her a green light to
promiscuity?“
“Parents who educate their girls can relax and can sign the refusal
form”.
“Women will not get cervical cancer if they make love with one
partner only”
“As far as I know, only prostitutes are at risk”
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25. Conclusion
 The findings are consistent with our previous face-to face
research (mothers’ perspective)
 Moral concerns about sexuality and promiscuity
 This study uncovers not only the negative attitudes but
also positive discourse around HPV vaccine.
 A high number of internet users expressed their need for
more and accurate information
 The elaboration of high-quality Internet based information
for vaccination decisions might be useful.
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26. Mass Media Coverage of HPV Vaccination in
Romania
Objective
 The study aims to explore the content and quality of HPV
vaccine media coverage in Romania.
Methods
 Sample included 271 articles (from newspapers, magazines,
videos, informational websites), published online between 1st
November 2007 and 31 January 2013.
 Content analysis (Morse & Field, 1995)

28. Findings
Tone:
 31.4% of the articles were neutrally disposed toward the
vaccine
 17% were mixed
 28.1% were negative or extremely negative
 23.6% were positive.
 Some titles include :
“Adolescent girl died after getting cervical cancer vaccine”
“Gardasil: poison for Romanian people. The vaccine is involved
in girls’ sterilization”.
25 articles: individual’ stories; only 3 as positive experience
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29. Concerns regarding HPV vaccination (%)
Side effects 36,9
Insufficient testing 19.2
Young age 5,9
Big Pharmaceutical companies 11,1
Financial interests 9,2
Encouraging promiscuity 1,8
Mandatory vaccination 1,8

30. Accuracy of vaccine information (%)
Vaccine
information Accurate
Non-accurate /
Incomplete Not mentioned
Efficacy 18,5 18,8 62,7
Dosing 27,7 1,1 71,2
Duration 8,5 5,2 86,3
Target age 28 26,2 45,8
Non-living
materials 6,3 1,5 92,2

31. Conclusions
 Readers were provided mainly with neutral and negative
stories about the vaccine, with some articles being
outstandingly negative, which is an unhelpful aspect, as
such reports might act as fear-eliciting messages.
Furthermore, most stories failed to provide
comprehensive information on HPV and vaccine.
 Findings support the necessity of more rigorous standards
when presenting vaccine information via media channels
and highlight the importance of improving
communication between the medical community and the
media.
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32. Healthcare Providers’ perspectives on HPV vaccines
Objective and Method
 To identify the attitudes of providers toward vaccination
and providers’ experiences with patients in relation to
vaccination
 Semi-structured interviews
 Thematic analysis
 Romania: 15 GPs, 2 paediatricians
 Croatia: 13 GPs, 4 epidemiologists
 France: 10 GPs, 6 gynecologists
 Greece: 9 GPS, 4 internal medicine, 2 paediatricians 32

33. Vaccine hesitancy amongst healthcare
workers and their patients in Europe

34. Findings
 Doctors’ opinions - on a continuum between vaccine
acceptance and HPV vaccine hesitancy.
 The majority recommend vaccination on grounds of benefits
of vaccination: effectiveness and utility.
 Some doctors had negative feelings related to the low uptake -
disappointment, regret, blame (for not being able to convince
about vaccine benefits), indignation.
 tendency to defer responsibility : “when asked, our role is to
inform, not to convince”.
 Physicians who clearly opposed vaccination (n=2) invoked
serious side effects due to adjuvant substances and considered
vaccine as useless and ineffective
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35. Improve information
Communication skills for doctor-patient conversations
Telephone lines
Control information provided in the media, journalists
More data on side effects
HCWs training
Stricter legislation
Defend physicians when side effects occur
Fines for parents who do not vaccinate
Legal action against anti-vaccination HCWs
Vaccination campaigns
Improve health system
Lack or delayed vaccines
Changes in vaccination calendars
Include more vaccines in national immunisation programme
Free vaccination

36.  HCWs are aware of the benefits of vaccination but do
have some concerns, especially about side effects
 Important impact of anti-vaccination content on the
media
 HCWs believe it is their role to respond to patient
hesitancy
 HCWs suggest to: improve information, develop
regulations, improve doctor-patient communication,
train HCWs in responding to patient hesitancy
In summary

37. Determinants of HPV vaccine acceptability in
young adults
Objectives
 This study uses an extended model of Health Belief
Model and aims to explore which factors predict
intentions to get the HPV vaccine in a sample of young
adults
Methods
Participants
 College students (n = 310, 80% females), aged 18 to 26
(M = 23.1, SD = 2.06), completed a theory-based survey.
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38. Measures
 Demographic and health-related variables
 Attitudes toward vaccines - assessed using 6 items
 HPV and HPV vaccine awareness and knowledge,
assessed with a 18-item scale adapted from past studies
(Fazekas, Brewer, & Smith, 2008; McRee et al., 2010).
 Vaccine-related beliefs and emotions (perceived
susceptibility to infection, perceived severity of infection,
perceived effectiveness and safety of vaccines, anticipated
inaction regret, anticipated worry about being infected
and about transmitting disease)
 Interest in learning more about vaccines
 Behavioral intention
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39. Findings
 2.9% reported having received the HPV vaccine
 8% reported that their GP recommended HPV vaccination
 91% reported low/very low perceived susceptibility to HPV
 30% believed the vaccine is not effective
 25% believed the HPV vaccine could have serious side effects
 23% believed the vaccine is safe
 17% said they would probably get vaccinated in the coming
12 months.
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40. 40

41. Predictors of vaccine acceptability
- anticipated regret (t=4.587, p<.001)
- perceived susceptibility (t=2.229, p<.05)
- perceived severity of HPV (t=2.460, p<.05)
- perceived vaccine safety (t=2.297, p<.05).
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42. The effects of message frames and self-other
appeals on HPV vaccination intentions
Objective
 We aim is to investigate the effectiveness of message
frames (gain vs. loss) and self-other appeals (outcomes-
to self vs. self and others) on respondents' intention to
obtain the HPV vaccine
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43. 43

44. Participants and Design
 Students (n=290) randomly allocated to one of conditions;
they read a brochure about HPV vaccines and complete a
questionnaire
 2 (frames: gain vs. loss) × 2 (outcome appeals: self vs. self
and partner) + control (no frame) between-subject design
1. Gain self (benefits of vaccination for self)
2. Gain collective (benefits for self and partner)
3. Loss self (costs for self if refuses vaccination)
4. Loss collective (costs for self and partner)
5. Control (no frame)
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45. Main Results
 For participants with preexistent negative attitudes, self-gain
messages worked best (p < .01);
 For those with favourable attitudes, collective-gain messages
worked best (p < .01).
 Findings suggest that it would be helpful to tailor messages
according to participants’ preexistent attitudes in order to increase
the rate of vaccination
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46. Conclusion
 Overall, findings highlight that vaccine hesitancy is complex and context
specific (social, historical, political & psychological dimensions that
influence vaccination uptake, such as fear, mistrust, control, blame,
responsibility and power, as well as specifics of current health system
changes)
 Many of the identified barriers and correlates of HPV vaccine acceptability
are modifiable and offer potential targets for future campaigns
 Effective HPV vaccination-promoting interventions are needed

47. Thank you!
adrianababan@psychology.ro
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