Knowledge, Beliefs and Communication Preferences with Regards to the HPV Vaccine; the Perspective of Unvaccinated Greek Adolescent Girls, Young Women, and Mothers of Vaccine-Eligible Girls

In Greece, human papillomavirus (HPV) vaccination is given free of charge but is not supported by an organised effort to increase participation; therefore, coverage is estimated at only 9% of the intended population. The investigation of complex aspects around HPV vaccination behaviour is particularly salient in this country, because HPV vaccines are provided on demand after prescription from a healthcare provider (HCP). In Greece, HCPs reportedly recognise the HPV vaccine as an important medical innovation but have concerns about its safety, effectiveness, and long-term impact. Hence, they do not consistently recommend vaccination and sometimes advise against it. In this context, the aim of this qualitative study was to investigate knowledge, beliefs, and communication preferences of Greek teenage girls, young women, and mothers in relation to the HPV vaccine.

Three targeted groups, recruited from Athens and Thessaloniki, were chosen to participate in the cross-sectional study: teenage girls (12-17) who are the main intended population for HPV vaccination, mothers of vaccine-eligible girls who are likely to influence their children's decision or make it for them, and young women (18-26) who are within the age range for vaccination but more likely to decide this for themselves. Six focus groups (5-8 participants) were conducted at the end of 2014. The discussion guide was based on issues raised by relevant studies, such as perception of personal risk, beliefs regarding the severity of HPV infection and cervical cancer (CC), beliefs about vaccines in general and the HPV vaccine in particular, perceived benefits and barriers, vaccine efficacy and safety, recommendation or influence of significant others, behavioural intentions and experiences of issues surrounding HPV, and reliability and quality of information received by the media.

Following administration of a pre-focus group questionnaire and discussion based on the discussion guide, participants were shown 3 types of stimuli:

1. Minutes 12.00 to 22.10 of the documentary 'Catching Cancer' (see below), which presents an outlook on the way viruses play a role in some cancers specifically, the role of HPV in CC and the introduction of the HPV vaccine.
2. Minutes 00.00 to 9.32 of a discussion, available online here, between a male Greek gynaecologist and HPV expert who had been invited to discuss HPV and the HPV vaccine with 2 female journalists/presenters within the context of a health programme broadcasted by a Greek state channel.
3. A leaflet titled 'Get vaccinated today! Vaccination to prevent human papillomaviruses causing cervical cancer and other serious diseases', produced by the Greek Organization of Child and Pediatric Gynecology, which followed a question-and-answer format.

Findings revealed that the mean HPV knowledge sample score was relatively low, with a mean score of 3.8 (standard deviation (SD)=1.94) out of a possible maximum score of 10, while mean knowledge scale scores differed across the 3 age groups. The majority of participants were aware of the link between HPV and CC, and most deemed CC a serious health issue that could have consequences for a woman's reproductive ability. As these were unvaccinated individuals, in their attempt to make a decision, they weighed their concerns about the risk of getting vaccinated against the benefits of protecting themselves against CC. This negotiation involved an active search of information about the HPV types the vaccine could guard against and the side effects commonly experienced by vaccine users. All the participants cited the novelty of the vaccine as the main barrier to vaccination. Several stated they had received conflicting advice from HCPs in terms of the vaccination recommendation, which made them question the reliability of the vaccine itself. Their concerns were further reinforced by testimonials they had read or heard about of individuals receiving the HPV vaccine and suffering serious side effects such as paralysis.

All participants stressed that they had information gaps around HPV and HPV vaccination. Teenage participants stated that their source of information was mainly their family, friends, doctors, and peers and that, if they were to look for more, it would be on the internet. Young women had heard about HPV at school or through their studies, while others recalled a Ministry of Health campaign for the vaccine. Some mothers had heard about HPV from the media or read about it on the internet, while others had read leaflets at the health service. They had asked their own doctors (i.e., gynaecologists) or their daughters' doctors but also asked for the advice of relatives who happened to be health professionals.

Mothers thought the HPV vaccination should be given by experts such as physicians in the context of a sexual health talk. Participants admitted the limitations they had in their roles as mothers due to the fact that they had no expert knowledge or authority in their daughters' eyes to deliver such sensitive information. Young women and teenage girls thought recommendations should come from doctors or pharmacists. They believed that information about sexual health should be given at the end of primary school as well as junior high and during high school. Participants of all groups highlighted the danger of administering the vaccine outside the context of a sexual health talk. In a conservative society such as the Greek one, the decision for vaccination was not seen as just a health-promoting decision but inadvertently symbolised young women's sexual debut.

All 3 age groups held strong general beliefs about the overuse of medications, which the researchers say is not surprising in light of frequent public announcements of Greek doctors' overprescribing. Furthermore, the majority of participants voiced the opinion that HCPs are eager to promote the administration of HPV vaccine and other medicines because they have an ulterior motive. Participants' indecisiveness with regard to the vaccination was enhanced by their concern that this medical innovation - namely, the HPV vaccine - might not be the medical recommendation a few years from now.

The decision-making process was based on participants' evaluation of risk. It is noteworthy that participants tried to make sense of the statistical figures they heard during the documentary and expert discussion. Some participants became confused when they tried to combine the information they heard from both stimuli.

Participants appreciated each of the stimuli formats for different reasons, which are outlined in the article. Many preferred the documentary, saying that it provided a context to the HPV vaccine and was more impressive in its presentation. In terms of content, they prefer a balanced approach to the HPV dilemma, which is more compatible with their own experiences and does not reinforce their concerns but rather provides answers to the issues they are struggling with - e.g., side effects. Participants thought that the medical expert in the interview video was too adamant with regard to vaccination; this came in sharp contrast to their own experience and did not address their concerns about safety.

In light of these findings, the researchers suggest that health policy adjustments should focus on ensuring that the public has access to appropriate and reliable sources of information in order to make an informed HPV vaccination decision. Specifically, in their estimation:

• Further research should be conducted on the physicians' role in the communication of health information, and support should be provided in the form of guidance, information, or resources;
• Health information provided by the media should be based on well-researched medical facts and presented by science journalists or science communication experts, taking into account factors such as format, message framing, and prevalent beliefs;
• The public's concerns should be investigated further through research and addressed via targeted public health campaigns; and
• Sexual health education should be given special focus at schools, local communities, and healthcare contexts.

In conclusion, some of the study's findings might be relevant for countries that, like Greece, have also adopted "on demand" HPV vaccination schemes or are currently considering an HPV vaccination policy.