Perception about Barriers and Facilitators of the School-based HPV Vaccine Program of Manizales, Colombia: A Qualitative Study in School-enrolled Girls and Their Parents

"...findings suggest the need for a comprehensive education program including mass media information to provide adequate information on how the HPV vaccine can prevent cervical cancer to help girls and parents make an informed decision about vaccination."

In Colombia, where the prevalence of cervical cancer is high, coverage of the human papillomavirus (HPV) vaccine has been in decline since its school-based implementation that country in August 2012. Given the lack of public confidence of the HPV vaccine, largely due to a mass psychogenic response after vaccination in 2014, uptake remains low. Therefore, this qualitative study was conducted among girls who had been eligible for vaccination in 2012 to 2014 and their parents to identify themes about barriers and facilitators towards acceptability and uptake of the HPV vaccine in light of the mass psychogenic event.

During the "El Carmen de Bolívar" event, which occurred from May to October 2014, about 600 girls reported a variety of symptoms that required medical attention; news and social media platforms were dominated by hundreds of videos and images of girls fainting and being carried into hospitals unconscious. Limited information about what the vaccine is and what it could prevent may have contributed to the general mistrust in vaccines and the attribution of the El Carmen de Bolivar event to the HPV vaccine. Despite the official finding that the event was due to a mass psychogenic reaction and not to biological factors associated with the vaccine, completion rates of all 3 doses dropped from 88% in 2012 to 5% by 2016.

Forty-nine girls (38 vaccinated and 11 unvaccinated) from 6 schools and 58 of their parents in Manizales, Colombia, participated in the study. Using a guide that was designed based on the Health Belief Model (HBM), the researchers conducted 19 individual interviews and 18 focus groups with an average of 5 girls each between September 2016 and February 2017. In the context of HPV vaccination, the HBM suggests that the intention to uptake the vaccine can be predicted by the individual's perceived severity of and susceptibility to HPV infection or cervical cancer, their beliefs about the benefits and barriers to being vaccinated, or signals for action or facilitators (e.g., a doctor's recommendation).

Selected findings:

• Cervical cancer awareness: Most parents, especially those of middle and upper socioeconomic levels, had some degree of awareness about the disease (30 of 58 parents). In general, parents considered the Pap smear and use of condoms as important prevention measures, while the vaccine was important only for very few parents of vaccinated girls of high socioeconomic status. Vaccinated girls showed more awareness of cervical cancer than those who were unvaccinated. In general, girls were unaware of the causes of disease.
• Awareness of HPV: Parents and girls from middle and upper socioeconomic levels showed some awareness about HPV, while those from lower socioeconomic levels and even among those who received the vaccination were unaware. Susceptibility to HPV infection was more frequent in parents of vaccinated girls of high socioeconomic level.
• Facilitators of HPV vaccination: The main facilitator for vaccine uptake for parents was the desire to prevent diseases in general; for girls, uptake was facilitated by receiving positive information about the vaccine. Participants consider schools to be ideal places to for HPV vaccine delivery, given that adolescents are generally healthy and do not need to see their doctor regularly.
• Barriers to HPV vaccination: The main barriers for parents not to vaccinate their daughters or complete the 3-dose course of the vaccine were the fear of adverse effects and the event of Carmen de Bolívar. For the girls, the fear of needles and the Carmen de Bolívar event were the main barriers. Another barrier was revealed to be lack of information: Girls and parents alike reported that the information provided by the schools and the healthcare provider was limited. Parents mentioned that the main sources of information were from the vaccination campaign, some doctors, the media, and from the girl herself. Only parents of unvaccinated girls from middle and high socioeconomic levels mentioned having obtained information from the internet. For girls, the main sources of information were from the vaccination campaign, television, and parents.

Reflecting on the findings, the researchers note that the HPV vaccine campaign message of "Que vivan las mujeres, que viva la vida" (Long live women, long live life) seemingly did not reach the intended population. This message emphasised that the vaccine prevents against HPV and consequentially cervical cancer (rather than focusing on its connection to sexually transmitted infections, or STIs). However, unexpectedly, both parents and girls in the study did not mention that the vaccine against HPV infections is also the main form of prevention of cervical cancer.

The researchers observe that declines of coverage in HPV vaccination have occurred following events similar to El Carmen de Bolivar around the world, which have been resolved successfully. For example, in Ireland, the government created an initiative called the HPV Vaccination Alliance, which united 35 organisations across the country to encourage all key stakeholders to actively promote the vaccine through a wide range of cross-sectoral strategies, such as mass media advertisement and differential training programmes.

In conclusion: "Following the mass psychogenic illness event in El Carmen de Bolivar, it is imperative that governmental and local authorities act promptly and appropriately to contain widespread misinformation and to minimize any long-term impact such an event can have on public health prevention of cervical cancer. It is also recommended not to suspend active recommendation of the HPV vaccine because this would increase uncertainty and loss of confidence in the vaccine....To encourage informed decision making about HPV vaccination, it is important that doctors become educators for girls eligible for vaccination and their parents. This would support the parents and girls in weighing the benefits and risks to vaccination..."