Background
The notion of vaccine hesitancy
Significance
Methods
Data collection
Characteristics | Percentage (%) | Number of People |
---|---|---|
Gender | ||
Female | 100 | 40 |
Age | ||
18–20 | 12.5 | 5 |
21–25 | 25 | 10 |
26–30 | 12.5 | 5 |
31–35 | 15 | 6 |
36–40 | 12.5 | 5 |
41–45 | 7.5 | 3 |
46–59 | 15 | 6 |
Marital Status | ||
Single | 57.5 | 23 |
Married | 32.5 | 13 |
Others | 10 | 4 |
Whether have gotten HPV vaccines | ||
Yes | 30 | 12 |
No | 70 | 28 |
Whether have gynaecological screening regularly | ||
Yes | 32.5 | 13 |
No | 67.5 | 27 |
Whether have children | ||
Yes | 32.5 | 13 |
No | 67.5 | 27 |
Ethics approval
Data analysis
Results
Individual level
Perceptions of HPV and HPV vaccine
Only a few participants knew that HPV can lead to genital warts; however, they rarely knew that HPV vaccination can also help prevent genital warts:We [my colleagues and I] saw an advertisement about the cervical cancer vaccine. It is said that if we want to protect ourselves from cervical cancer, then we should get the jabs. The advertisement just mentions cervical cancer … It is an advertisement for cervical cancer. I don’t know if the vaccine can prevent other diseases. [Participant 18]
The most prominent understanding among participants was that HPV vaccination can prevent cervical cancer; most were unaware of the other uses of HPV vaccine, although they knew that the vaccine has other preventive uses:HPV mainly results in cervical cancer? And other diseases such as … hmm … I am not sure … but maybe something related to the sexual organ, like [genital] warts. I have heard about HPV vaccination; it is for the prevention of cervical cancer. [Participant 6]
In most cases, participants called HPV vaccine “cervical cancer vaccine.” This “nickname” made them believe that the vaccine is exclusively for women and only for the prevention of cervical cancer:I know that the vaccine can prevent cervical cancer and hmm … some kinds of viruses … I remember that I once got a leaflet stating that the vaccine can prevent some diseases … and cervical cancer. Sorry, I can recall cervical cancer only. [Participant 1]
The Chinese naming of HPV vaccine thus 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:When I saw the information about the vaccine, I thought that it is great to have a new way to protect women. I think the vaccine is for women only, because the vaccine is a cervical cancer vaccine, so it prevents cervical cancer. Only women will suffer from it. Men will never have this disease. [Participant 37]
Besides the relationship between HPV and cervical cancer being the most prominent understanding among participants, the relationship between HPV and AIDS was also a prominent stereotype. HIV is literally similar to HPV, which seemed to confuse some participants as they misinterpreted HPV as HIV:There are two brands of HPV vaccines. One has Ah Sa [a female Hong Kong singer] as the spokesperson, and the other has GEM [a female Hong Kong singer] as the spokesperson. We [my friends and I] call those vaccines as “Ah-Sa-vaccine” and “Ah-GEM-vaccine”. I think this vaccine is clearly for women only, because Ah Sa and GEM are women. [Participant 4]
HPV? Is it the cause of AIDS? I remember that AIDS is caused by a virus that has these 3 alphabets. [Participant 35]
Perceived worthiness of HPV vaccine
It appeared that if the vaccine was offered at a discounted cost, participants had a higher incentive to get vaccinated and were thus more motivated:I could get a discount [for the HPV vaccine] when I was studying at university. However, I didn’t have a stable income at that time, so I did not get vaccinated. It doesn’t mean that I didn’t want to get the vaccine, but just that I didn’t want to spend such a large amount of money on the vaccine at that time. It was more sensible to spend those thousands on other more important things at that time. Getting vaccinated was not a priority for me at that time. [Participant 7]
On the other hand, price of the HPV vaccine can be varied in different private practice healthcare providers, and some participants were suspicious about the varied costs of the vaccines, making them hesitant to get vaccinated:I took the jabs when I was a final year [undergraduate] student. There was a promotion booth [of HPV vaccine] in the campus … It was pretty expensive, but the cost had already been discounted. It would be even more expensive if I took the jabs outside the campus after I had graduated. [Participant 4]
I wanted to get the vaccine before, so I asked [the clinic] about the cost [of the HPV vaccine]. I was told that there was a vaccine which could prevent 9 types of (HPV) viruses, costing around 2,000 dollars. I thought the cost was okay. But later when I asked [about the vaccine] again, the clinic told me that there was a new [HPV] vaccine which could provide more protection but would cost around 4,000 dollars. It was really expensive … I wondered whether launching a new vaccine is a way for pharmaceutical companies to make profit. Finally, I did not take the vaccine. [Participant 35]
Non-vaccinated participants perceived the plan of getting married as remarkable to make the vaccine worthy for them. The perceived worthiness of the HPV vaccine was also related to the perceptions of participants about its protective value:I read the advertisement of HPV vaccination... I know that the vaccine can prevent cervical cancer. However, I don’t think I have an urgent need to get the vaccine, because I still do not have any plans to get married. There is no use to get vaccinated if you are not getting married. I may consider getting vaccinated if I am going to get married. [Participant 24]
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 majorly 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.I know the vaccine can prevent cervical cancer. However, I also know that there [the vaccine] is no 100% guarantee [for the efficacy]. I still have the chance of getting cervical cancer even after getting vaccinated. Then what is the point in spending such a large sum of money for a vaccine that cannot provide full protection to me? [Participant 25]
The advertisement said that all women need the vaccine … But as I know, this virus is sexually transmitted, so I think only those who have many sexual partners and frequent sexual activities are at a higher risk … I don’t think I am at a high risk; I am not that kind of person, so I don’t think I need the vaccine. [Participant 7]
Hence, participants believed that there exists a close relationship between sexual activities and cervical cancer incidence. Most participants had the perceptions that HPV, and thus cervical cancer, is sexually transmitted. They commonly possessed a stereotype of being promiscuous, which, as per the participants, referred to having more than one sexual partner and indulging in frequent sexual activities. This in turn would be harmful to the uterus, increasing the chances of developing cervical cancer. As all non-vaccinated participants expressed that they were either abstinent or only engaged in sexual activities with one stable partner, they perceived themselves as being at a low risk of cervical cancer; consequently, they believed that there was no real need of being vaccinated for HPV.Sex is a way of transmitting HPV. If people engage in sexual activities more and if they have many sexual partners, they will have a higher chance of getting the virus and related diseases for sure. Also, sex can hurt the womb. More sex more harm … For those who do not indulge in sexual activities often or have just one sexual partner, I do not think they need the vaccine. [Participant 25]
The pattern and frequency of sexual activities were thus interlinked with the perceived worthiness of getting vaccinated for HPV; these were the other key determinants affecting the decision-making process. The perceptions about sexual activities in relation to HPV vaccines as possessed by the participants, however, were to some extent contradictory. On one hand, having no sexual experience was believed to enhance the efficacy of HPV vaccine, whereas on the other, no sexual experience also reduces the risk of getting cervical cancer and thus the perceived need of getting vaccinated.When I was about to take the first dose, the nurse said that the efficacy of the vaccine is better for those who have never had any sexual experience. As I have had no sexual experiences, I think I can get the most from the vaccine and the vaccine is worthy. However, some of my friends, after whispering to one another, decided not to get the vaccine; I guess they must have had sex before, and getting the jab would be a waste. [Participant 1]
History of experiencing gynecological conditions
The presence of gynecological conditions in the family and social network of participants was also closely related to their awareness and perceived risk of getting cervical cancer—such a presence motivated them to think about getting vaccinated:Irregular menstruation is a symptom showing that the uterus is weak. This indicates that the uterus is not strong enough to fight against the disease [cervical cancer]. Therefore, it is better to get vaccinated if you have menstruation problems. [Participant 40]
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. Such experiences by those in their social network familiarized participants with cervical cancer, serving as a determinant in their decision-making process:Having uterus-related problems is not rare in my family. I have three elder sisters and two of them suffer from [uterine] fibroids. Their daughters have [uterine] fibroids as well … We [my sisters and nieces] all concern about our uteruses, so we used to talk about the [HPV] vaccine. We have been thinking if the [HPV] vaccine can provide more protection to us … My sisters [who suffer from uterine fibroids] have had their uterus removed already, and my nieces got the [HPV] vaccine soon afterwards [after we have discussed the efficacy of the vaccine], hoping that the vaccine can provide more protection to them. [Participant 26]
However, in a few cases, the experiences of family members and those in the social network also had a negative influence on the decision-making process of a few participants, which in turn reduced their motivation to get vaccinated:I did not take the cervical cancer vaccine in the past. However, many of my friends have been suffering from cervical cancer in recent years. I know them, and I know they are well-behaved and have led a healthy lifestyle. I did not expect them to have cervical cancer. My friends’ experiences have motivated me to take the vaccine now, because cervical cancer can happen to good women as well. [Participant 9]
In contrast, the absence of gynecological conditions in the family and social network of participants, particularly in case of non-vaccinated participants, resulted in unawareness among them regarding the risk of cervical cancer and the need of getting vaccinated:Everyone can have cancer in any part of the body … so there is no need to take any special preventive measures against cervical cancer. To prevent cervical cancer, or I should say all types of cancer, I still believe we should use a more holistic approach to enhance our health … I live in a healthy way, so I don’t think I need the [HPV] vaccine. If I have been leading a healthy lifestyle but still I get that cancer [cervical cancer], then that is fate. You can do nothing to change your fate; even if you can save yourself from cervical cancer by getting vaccinated, you will still suffer from other cancers. [Participant 29]
Thus, the decision-making process regarding HPV vaccination was influenced if participants themselves or people in their social network experienced gynecological conditions. Such experiences familiarized participants with cervical cancer, enhancing their awareness and perceived risk of cervical cancer, and eventually their motivation to get vaccinated.I don’t think I am at a high risk of getting cervical cancer … None of my family members have cervical cancer, so I suppose I also have a very low chance of having it. Therefore, I don’t think I need to get vaccinated. [Participant 3]
Micro-social level
Acquisition of information on HPV vaccines
On the other hand, difficulty in obtaining information and confusing information discouraged participants:I chose that one [vaccine] with Ah Sa [female celebrity] as the spokesperson, because the clinic provided more information about that vaccine than the other one [vaccine] with GEM as the spokesperson. [Participant 5]
The efficacy and side effects of HPV vaccine were the most needed information that could influence the decision-making process of participants. Merely knowing its efficacy against cervical cancer was far from adequate for most participants. Rather, 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:I have been thinking about taking the vaccine. There are 9-in-1, 6-in-1, and 4-in-1 vaccines, but the information on these vaccines is rare and too confusing. I don’t really know the concrete difference among the three vaccines, and it is difficult to obtain more information. I think I will need to obtain more information before I can decide whether I would want to get vaccinated, and if so, which one I would choose. I don’t know where to get more information, so it is difficult for me to decide. [Participant 14]
I know that the cervical cancer vaccine can prevent against cervical cancer, but I do not know if it is okay for me to get the jab. I suspect I am too old to get it. [She was 56 years old.] I have tried to search for the answer but failed. What I know is that there is a vaccine called cervical cancer vaccine from the leaflets and bulletins that I got from clinics, hospitals, or even from The Family Planning Association of Hong Kong [a non-government organization in Hong Kong providing medical and counselling service in sexual and reproductive health]. That’s all what I know about this vaccine. No one has told me whether I am eligible to get the jab. [Participant 36]
Intermediate-social level
Absence of preventive care in the healthcare practice
Lack of explanation by healthcare providers also served as a barrier:Indeed, I want to ask the doctor about the cervical cancer vaccine. However, the consultation is too rushed. There is no time for me to ask any questions. Similar to most typical consultation scenarios that you can imagine, the doctor just asked me when I got sick and the symptoms, and then simply gave me some medicines and asked me to leave. [Participant 8]
Consultation with doctors in Hong Kong primarily involves discussions on curative and treatment methods, rather than on preventive measures. People visit doctors mainly when they are sick. Doctors thus do not show much enthusiasm in dealing with inquiries pertaining to vaccines. Moreover, several participants fail to realize that can in fact discuss issues pertaining to vaccination with doctors:I have asked the doctor once in the past whether I need to get the jab. He responded by asking me how old I was, and then he said I didn’t need the jab. That’s all! The doctor didn’t explain anything to me. Is it because I am too old for the vaccine or could there be other reasons? I have no idea because the doctor did not explain anything. [Participant 17]
Vaccination is a preventive intervention. In the typical clinical practice in Hong Kong, it is unusual for patients and doctors to discuss preventive care, such as vaccination, within the premises of consultation. A few participants still did mention that their doctors suggested them to get vaccinated against HPV as part of consultation; this however made participants suspicious of the intention of their doctors:I have many questions about the vaccine, but didn’t realize that I could ask my doctor. When you go to see a doctor, you are sick. Therefore, I don’t want to be in the clinic for long. I just want to see the doctor for my sickness, have it dealt with, and then leave as soon as possible. I have never thought of asking doctors about vaccines, because I go to them for getting treated, not for discussing vaccination. [Participant 25]
Although some participants already had an established relationship with their doctors, the suggestion of vaccination, in most cases, made them suspicious of the intention of their doctors:The doctor has never mentioned this issue [HPV vaccination] in the past consultations. I didn’t ask him. However, he suddenly suggested the vaccine to me … I was a bit shocked and wondered if he wanted to make more money by selling the vaccine to me. [Participant 28]
HPV vaccines in Hong Kong are mostly available on a self-pay basis and administered by private practice doctors. As preventive care is not a clinical norm in Hong Kong, doctors suggesting vaccination to patients is sort of exceptional; such advice can in fact lead to doubt and suspicion among patients. Also, as stated by participants, they had no intention to ask their doctors about getting vaccinated because the stereotypical linkage among doctors, sickness, and treatment is much stronger than the linkage between doctors and preventive care. Thus, if vaccination was recommended by doctors, participants became suspicious and assumed that doctors had commercial intentions. Such social norms in clinical practice thus negatively influenced the decision-making process of participants.My gynecologist had suggested me to take the vaccination. However, I do not think I have any such need because the pap smear result was normal at that time, so why do I need to take the vaccine? After the doctor informed me that my pap smear result was normal, he then went on to ask me if I wanted to take the jab. His tone, facial expression, and gesture were quite suspicious to me. He smiled maliciously, making it seem as if he was selling the vaccine to me rather than giving professional advice. [Participant 36]
From an overall perspective, information pertaining to HPV vaccination was a significant factor facilitating the decision-making process. However, the information had to be perceived as trustable and credible. Unfortunately, such information was limited, constraining the decision-making process of participants.If it is an important vaccine for women, why doesn’t the government enforce all women to take it? Yes, if the government takes a more active role in promoting the cervical cancer vaccine, I will think it [vaccination] is important and urgent. [Participant 32]
Macro-social level
Stigma associated with HPV vaccination
Consequently, some participants were not in the favor of getting vaccinated:The moral standard in our society is not good already. I feel some girls may think that being vaccinated will allow them to have sex more freely and openly. They would think they can do whatever they want after getting vaccinated. I think this is not good. Education is needed for these girls to have a correct attitude toward sex. They won’t care about these [moral] issues if they know that they are totally safe from cervical cancer after the vaccination. [Participant 23]
Thus, 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. This perception also represents a stereotype in vaccinated women who are to be perceived as violators of the moral value system. Such perception indicates that the cultural meanings of immorality and promiscuity in the context of HPV vaccines influence the decision-making process of participants. Such a cultural stereotype did not merely influence the need to get vaccinated, but it also intensified the moral burden on those who did get vaccinated.Probably one of the negative consequences of promoting cervical cancer vaccination is that girls may think that “I won’t get cervical cancer anymore,” so they have nothing to fear and may have casual sex with others more freely. [Participant 26]
Distrust on HPV vaccine
Most participants were not exactly aware of the side-effects of HPV vaccines; they still stereotyped the vaccine as being able to cause death and paralysis.I have read some news on the Internet reporting the serious side-effects of getting vaccinated. I’m really worried if the vaccine is safe or not, so I still have not made up my mind. I want to wait to see if there are any side-effects being reported … I cannot remember [the side-effects] exactly. I just have heard that some people died after getting vaccinated, while others have gotten paralyzed. I remember these side-effects happened overseas, but they sound horrible, so I dare not get the vaccine … I think the news is trustable. After all, I do not think doctors or drug companies [pharmaceutical companies] will inform you of these side-effects because they are selling the vaccine. [Participant 37]