New Vaccine Introduction: Strengthening Health Literacy to Increase Health Equity

"Immunization uptake is related to inequity factors such as parental education and income, and identifying the determinants of vaccination allows countries to enhance the equity in uptake....Improving health literacy - supporting intended beneficiaries in better understanding and using information about vaccination - is a critical factor in this."

Despite scientific consensus about the safety and effectiveness of human papillomavirus (HPV) vaccines, HPV vaccine controversies have challenged health authorities in countries such as Colombia, Denmark, Ireland, and Japan, with misinformation being shared globally. With the hope of avoiding the erosion of trust that such controversies can engender, Armenia, Georgia, and the Republic of Moldova requested support from the World Health Organization (WHO) as they introduced the HPV vaccine in 2016 and 2017. As part of this process, formative research was conducted with key groups to inform introduction strategies and communication plans. A key aim of this research was to gain insight into the vaccination-related health literacy skills of the intended beneficiaries. This article shares the results of these investigations.

The researchers provide context for the studies, explaining that countries of eastern Europe have undergone political and social transformations in recent decades that have led to an increase in not only individual decision-making power but in the internet and social media and, thus, the number of media and information sources. As a result, health literacy expectations and requirements of parents have changed, as have the expectations and requirements of healthcare providers and educators.

Focus group discussions (FGD) and face-to-face in-depth individual interviews (IDI) were conducted among 218 participants: N=73 Armenia, N=64 Georgia, N=81 Republic of Moldova. They included parents, teenage girls, doctors and nurses, teachers, and a priest. Despite the differences in language and culture among the 3 countries, many findings were consistent. In brief, they include:

Barriers and drivers to positive HPV and general vaccination behaviours:

• Respondents in all groups across the 3 countries generally agreed with the need for vaccination and prevention of disease. Yet some look back with nostalgia on a simpler past when vaccination decisions were taken centrally, meaning that neither individual parents nor healthcare providers had to take responsibility for the consequences and "things seemed safer".
• The greatest concern about vaccine safety is the fear of adverse events following immunisation (AEFI). In reaction to parents' fears of AEFI, along with their own fears of being blamed, some doctors agree not to vaccinate children when parents are anxious.
• The dual system of free vaccines provided by the state versus self-paid vaccines from private providers complicates the perception of vaccine quality and safety and affects trust in the national health systems of the Republic of Moldova and Georgia.
• Questions arose during the research from all groups, except teenage girls, about the age of the recipients and the reason for HPV vaccination.
• Misplaced fears of harm to girls' future fertility were widespread; even healthcare providers who favoured the vaccine were affected by stories circulating on social media with misperceptions about the negative effects of the HPV vaccine on reproductive health. Both parents and doctors talked about social media stories of AEFIs from HPV vaccination in other countries.

Ideas for communicating the introduction of the HPV vaccine:

• An effective message for the promotion of the HPV vaccine could be that fertility is, indeed, protected when cervical cancer is prevented.
• Mothers say they are influenced by those they can relate to, including bloggers. They want healthcare providers to know the answers to questions about what they have seen online. Ideally, mothers said, they would like to see information from credible sources online, too.
• Healthcare providers want an expert source, online or in person, to whom they can go for answers, so that they, themselves, can become expert sources for parents.

In short, a diversity of factors was shown to affect health literacy and vaccination behaviours in the 3 countries: individual misperceptions, confidence, knowledge, and capacity of both healthcare providers and parents, as well as cultural, societal, historic, and community factors.

The researchers say that the findings of the studies mobilised immunisation programmes in the 3 countries to challenge their own preconceptions (e.g., "misunderstandings, confusion and fears were much more widespread than anticipated") and develop HPV messages and plans tailored to the meet the needs of different groups for HPV-vaccination-related health literacy. For example, the finding that increased decision-making power at an individual level creates uncertainty, which also affects healthcare providers, clarified that providers need to be a priority group in themselves and not just a channel of communication.