Social and Cultural Construction Processes Involved in HPV Vaccine Hesitancy among Chinese Women: A Qualitative Study

The uptake rate of human papillomavirus (HPV) vaccine among women in Hong Kong is very low: only 2.9% of adolescent girls and 9.7% of female university students received HPV vaccination in 2014. This study investigates the decision-making process of HPV (non) vaccination among Chinese women in Hong Kong; it does not merely investigate the barriers that make women reluctant, but it also examines factors that motivate them to get vaccinated. It uses the framework of Critical Medical Anthropology (CMA), which holds that a person's health behaviour and perception are to be influenced by 4 social levels: the individual, micro-social, intermediate-social, and macro-social.

Vaccine hesitancy is one of the commonly used frameworks to understand the low acceptability of vaccination, and the researchers investigate this notion. Advancements in technology and expansion of capitalism, mass media, and industrialism across the globe have contributed to the development of the post-traditional society. In this context, vaccine hesitancy should not be interpreted as merely a behavioural outcome; it is more appropriate to consider it as a decision-making process. The decision of whether to get vaccinated does not necessarily represent the views of an individual on vaccination; it is, rather, an empowering process that involves questioning and assessing risk. The focus should not only be put on the decisions made by an individual but also on the factors influencing the decision-making process, say the researchers.

Forty female Hong Kong Chinese participants aged 18-58 years, 30% of whom had received an HVP vaccine, were interviewed between May and August 2017. Per the CME, the rationale behind the decision-making process of participants regarding HPV (non) vaccination involved a combination of individual, social, and cultural factors at 4 social levels. Themes are shared, illustrated by quotations from participants:

1. Individual
   • Perceptions of HPV and HPV vaccine: The Chinese naming of HPV vaccine ("cervical cancer vaccine") led participants to focus on its efficacy against cervical cancer only and overlook its other preventive uses. In addition, female celebrities involved in promoting the vaccine via advertisements, which most participants found impressive, further presented the vaccine as being exclusively for women. Some participants misinterpreted HPV as HIV.
   • Perceived worthiness of HPV vaccine: The cost of the vaccine appeared to be a remarkable factor in the decision-making process. However, in addition to the actual monetary value of the vaccine, cost consideration was also based on the perceived worthiness of the vaccine, which was influenced by the risk perception of developing cervical cancer - related to marriage plans in most circumstances - and/or other HPV-associated conditions, as well as the perceived protective value of the vaccine. Sexual experiences and frequency of sexual activities were closely related to the perceptions of participants about the worthiness of getting vaccinated for HPV. Another factor influencing the decision-making process was the history of experiencing gynaecological conditions. Besides the family members of participants, the experience of people getting cancer, particularly cervical cancer, in their social network also enhanced their awareness of HPV vaccination.
2. Micro-social: Sufficient information regarding the vaccine served as an important motivation factor for most participants; difficulty in obtaining information and confusing information discouraged others. The eligibility to get vaccinated, duration of efficacy, and conditions that the vaccine could prevent were key insights that participants sought; such information was, however, seldom available.
3. Intermediate-social: Consultation with doctors in Hong Kong primarily involves discussions on curative and treatment methods, rather than on preventive measures. As preventive care is not a clinical norm in Hong Kong, doctors suggesting vaccination to patients is rather exceptional and even led to doubt and suspicion among some participants. Participants perceived the information provided by the government as more credible and reliable than that provided by their doctors.
4. Macro-social
   • Stigma associated with HPV vaccination: Promiscuity was commonly perceived by participants as an important cause of cervical cancer. HPV vaccine was perceived as a facilitating agent that could encourage immoral, promiscuous, and unsafe sexual behaviour in vaccinated women, as they would no longer fear cervical cancer.
   • Distrust of HPV vaccine: Study participants were also concerned about the side effects of the HPV vaccine. Some were worried because of the first-hand experiences of people in their social network, but most were worried due to news reports on the side effects, which they often obtained from the internet. Participants perceived news reports and the internet as relatively more credible sources of information than private practice doctors.

Reflecting on these findings, and in the context of social constructionism, the researchers suggest that understanding of study participants regarding the vaccine was related to the social processes of:

• Feminisation: "The imbalanced degree of emphasis on the efficacy of HPV vaccines against cervical cancer and other HPV-associated conditions has resulted in an imbalance in the promotion of HPV prevention, presenting women as being more vulnerable to HPV than men in the social discourse....The HPV discourse focusing on women reinforces the patriachal belief that women are responsible for reproductive health in heterosexual relationship..."
• Moralisation: "HPV vaccine...was perceived to be most needed by women who engaged in promiscuous and frequent sexual activities, serving as a subtle encouragement for having casual and immoral sexual behaviour, both of which are regarded as cultural taboos in Hong Kong. This stereotype contributed to a low perceived risk among participants due to their perceived moral sexual behaviour, which thereby led to their low perceived needs of getting vaccinated....Women are not only being culturally controlled for their (sexual) behaviours but also being deprived of having the rights to proactively protect their health, leading to their limited accessibility and health inequality in pursuing this preventive health behaviour."

Furthermore, participants were reluctant to receive HPV vaccination considering "the weaknesses of the macro-healthcare system and problematic doctor–patient relationship, which in turn affected their decision-making process". The healthcare system of Hong Kong follows a dual-track system, encompassing both the public and private sectors. "[P]articipants perceived private practice doctors as having a stereotypical relationship with business and profit-making....This embedded distrust on private healthcare could extend the distrust on HPV vaccines, particularly because the vaccine is solely available via the private healthcare section for most people in Hong Kong at the study time. The commercial stereotype attached on private practice doctors influenced the perceived creditability of the information and understanding of the needs and efficacy of HPV vaccine."

In conclusion, the study findings indicate that the decision-making process regarding whether to receive HPV vaccination is a complex one; the decision of HPV vaccination was affected by the assessment of worthiness of the vaccine, which in turn was affected by diverse perceptual, social, cultural, and structural factors, rather than simply the monetary cost. Structural factors also matter - in the absence of trust on private practice doctors, government health authorities "should take more proactive action in promoting HPV vaccination considering the trust from public."