HPV-Vaccine Hesitancy in Colombia: A Mixed-Methods Study

"Trust in medical recommendations and campaigns focused on the idea that vaccination is a way of protecting daughters from cervical cancer could improve HPV vaccine uptake."

In Colombia, the uptake rate of the human papillomavirus (HPV) vaccine dropped from 96.7% after its introduction in 2013 to 9% in 2020. In 2014, a group of young women in a Colombian coastal town who had been vaccinated experienced a mass psychogenic response including fainting spells, weakness, limb paraesthesia, chest pain, tachycardia, and headaches (the "Carmen de Bolívar" event). The purported vaccine side effects were videoed by various media outlets and shared widely on social networks. While the Instituto Nacional de Salud Colombiano (Colombian National Health Institute) conducted a rigorous epidemiological study of this event and did not find any organic association between the vaccine and symptoms described, the lingering effects of the event continued to lower HPV vaccine rates. This study identifies the behavioural components of HPV vaccine hesitancy among girls aged 9-15 and their families in Medellín, Colombia. Its findings are intended to inform a subsequent efficacy trial of a behavioural intervention to decrease HPV vaccine hesitancy.

This study draws on the COM-B model (capability, opportunity, motivation, and behaviour), which posits that behaviour change is influenced by 3 factors: (i) capability, having the physical and psychological abilities to engage in the behaviour; (ii) opportunity, having the physical or social opportunities to engage in the behaviour; and (iii) motivation, psychological processes that energise and direct behaviour, such as the belief that a behaviour is important and/or socially desirable.

The researchers conducted a convergent mixed-methods study in which 196 parents/caregivers responded to an online questionnaire, and 10 focus groups were held with 13 of these parents/caregivers and 50 age-eligible girls. In this sample, 57.1% of participants had not initiated vaccination. The paper presents both quantitative and qualitative findings aligned with the COM-B model.:

• Capability
  • Lack of information: Most participants perceived a susceptibility to cervical cancer and HPV and were aware that their daughters should be vaccinated, but 69.4% stated they had not received any information about the vaccine. Qualitative analyses confirmed that parents did not have enough information about the vaccine and vaccine programmes, and some cited misinformation about the Carmen de Bolivar event. Further, many still remembered the images of the women and girls who fainted en masse during that event.
  • Relationship between HPV and cervical cancer: Among all the focus groups of girls, cancer in general meant severe disease and death as a possible outcome. Girls recognise the value of the vaccine for reducing HPV susceptibility and severity. The participants imagine (incorrectly) that the vaccine puts a little bit of the virus into the body; thus, if they get the disease, it will not be serious.
• Opportunity - In focus groups, parents mentioned that healthcare providers and schools were trusted information sources. Girls tended to trust their families, especially their mothers.
• Motivation
  • The vaccine as an act of care: Most parents considered that vaccination is a form of protection and care for their daughters, which leads them to demand clear information about its effectiveness and safety. Often, parents mentioned the Carmen de Bolívar event and its role in their uncertainty about the impact of the vaccine.
  • Respect for the personal decision to be vaccinated: Some participants reported that vaccination is an individual act and at the same time, an act of collective responsibility. The decision cannot be forced, however. Girls understood that to access to the vaccine they must go through two gatekeepers: first their parents and then their healthcare provider, acknowledging that, as minors, the decision rests with the parents.
  • Association of HPV with sexuality: Some parents stated that HPV infection occurred because people start sexual life early; they considered it an adult issue and did not consider their daughters susceptible to infection at their young ages. Some parents state that prevention can be conducted through education in values rather than talking about sexuality openly.

One theme that was transversal to each COM-B component was the impact of COVID-19 on the conception of HPV. In Colombia, greater understanding of COVID-19 has allowed certain anti-vaccine discourses to be demystified (relatives of participants who were anti-vaccine but were now vaccinated) and negative ideas about vaccines to be discredited. Yet, especially in younger girls, different forms of HPV and COVID-19 transmission, prevention, vaccination components and dosage, and side effects can be confused. Regarding "opportunities", the pandemic further limited access to the HPV vaccines and reduced the importance of health campaigns focused on HPV vaccines.

The study's discussion section reflects on the findings and recommends ways forward in line with each of the COM-B components. For example:

• In terms of capability, research has indicated that simply providing information does not cause a change in vaccination behaviour. As suggested here, perceived susceptibility to HPV is a more promising intervention approach. Qualitative data from the present study revealed some unrealistic parental views of their daughters' susceptibility to HPV; many parents thought that since their daughters are young, they were far from starting their sexual life. World Health Organization (WHO) communication guidelines cited in this paper include educational interventions designed to increase the perception of susceptibility and the consequences of HPV infection.
• In terms of opportunity, previous studies have found that the percentage of healthcare providers (HCPs) who speak with parents about HPV vaccines for their children is very low. However, HCPs are critical to HPV vaccine uptake, and a provider focus has been recommended by the HPV Prevention and Control Board of Colombia. Broader implementation is a next step, as is making vaccination access easier by returning to the strategy developed in 2012 that situated the HPV vaccination programme in schools.
• In terms of motivation, although most participants in this study trusted the vaccine information received and the healthcare system providing it, some were distrustful of vaccine safety, efficacy, and potential adverse effects - perhaps in part due to the widespread coverage of the 2014 Carmen de Bolívar event, which still remains in the public's memories. Creating opportunities for public discussion, led by trusted healthcare providers, for example, could help to allay parental fears and increase HPV vaccine uptake. Parents and educational institutions should be involved in the co-design of these public forums.

In conclusion, the "COVID-19 pandemic has highlighted the threat of an infectious disease and has increased awareness of the vaccine-development process, since many parents had never seen the devastating consequences of an infectious disease before 2020....This creates an opportunity to generate awareness about HPV and its relationship with cervical cancer, but also to promote the use of the vaccine as the best way of preventing future complications."