Overcoming Vaccine Hesitancy Hurdles
By Emma Holloway, Fourth-year Undergraduate Student/Research Assistant and Elysée Nouvet Associate Professor, Faculty of Health Sciences
Most Canadians have been vaccinated against COVID. However, as of mid-February 2022, 15.79% are still hesitant and remain unvaccinated (Government of Canada, 2022). In the US, this number sits much higher: at 24% (Centers for Disease Control and Prevention, 2022). We have seen how grave the consequences of this can be (e.g., being 11 times more likely to die from COVID than those who are fully immunized) (Romo, 2021). Vaccine hesitancy, however, is not just a problem relating to the COVID vaccine. Defined as “the reluctance or refusal to vaccinate despite the availability of vaccines,” vaccine hesitancy is considered a serious global health challenge (World Health Organization, 2019).
Vaccine hesitancy is not about access, but about trust, mistrust, and sociocultural values. It is often entangled with mistrust of vaccine developers’ intentions in an era of vaccines being developed by private industry instead of governments (as they once were), and/or mistrust of authorities or organizations promoting vaccination as safe. During the West Africa Ebola outbreak, for example, many individuals in Guinea and Sierra Leone ran and hid from teams of researchers offering experimental Ebola vaccines. Such behaviour is not irrational but founded in histories of foreigners in the country (colonialists) using the bodies of black subjects for their own profit, as well as histories, in the case of Guinea, of the government being perceived by historically marginalized populations as willing to harm its own population (Wilkinson & Leach, 2015). Understanding vaccine hesitancy is key to increasing coverage, but this cannot occur in the absence of rich contextual analysis.
In 2022, funded by Merck, we are working with a team from Cameroon as well as McMaster University to advance understanding of human papillomavirus (HPV) vaccine acceptability and hesitancy in Cameroon. At the core of this study will be key decision-makers in HPV vaccination in this context: parents of girls aged 8 to 14. The goals of this study are to (1) evaluate the knowledge, beliefs, and attitudes of parents of female children in Cameroon regarding the HPV vaccine and (2) learn of possible interventions to improve acceptance of the vaccine in this area. The hypothesis is that willingness to get the HPV vaccine depends on both the public’s understanding of implications of an HPV infection and understanding of the benefits of the vaccine in preventing further illness. This study will feature semi- structured interviews with parents of female children in Northwest Cameroon, who either have or have not opted for HPV vaccination for their girls.
The global burden of HPV is great, but it is especially pronounced in low- to middle-income regions, like Sub-Saharan Africa (SSA). Eighty percent of all cervical cancer cases diagnosed are in SSA, and it is the leading cause of death among women here (Poole et al., 2013; Remes et al., 2021). Of cervical cancer cases, 60 to 70 percent are the result of infection with HPV, which can be easily prevented by getting the vaccine (Ngcobo et al., 2018; Poole et al., 2013). It can be hard for some to understand why a parent would not want to vaccinate their child, especially where a vaccination is proven to save lives. In a place like Cameroon, the primary health care system is seriously unfunded. This renders primary disease prevention (e.g., getting vaccinated) all the more vital for the protection of one’s health. In Cameroon, research to date suggests access to information may be part of the issue.
Many young Cameroonian girls and their parents do not know about HPV or that it carries a high risk for cervical cancer, or that a vaccine to prevent it even exists at all. If they do have some knowledge, it is often wrong (i.e., not scientifically accurate), misleading, or negative (Ngwa, 2021). It has also been suggested that hesitancy for the HPV vaccine might be higher than for other childhood vaccines in the country (Ngcobo et al., 2018). Why this is the case is the key question our team is investigating.
Although social and cultural construction processes are considerably more difficult to change than physical barriers, it is pressing to uncover all the different hesitancies as to why, on the bases of what ideas or preferences, vaccines may be avoided. Addressing women’s health issues, like HPV and cervical cancer, can have unique barriers because of gender differences.
The HPV vaccine is best administered to young girls ages 9 to 14, to ensure full coverage (usually 3 vaccines administered within a year) before girls are forced into or choose to become sexually active (Remes et al., 2012). Worldwide, the HPV vaccine has been met with hesitancy when it has been (mis)perceived as endorsing immoral sexual activity. Women across the world report feelings of intense guilt and shame, and that they are being judged or even rejected by their families, friends, partner, etc., in opting to get the vaccine if it is associated with promiscuous intent or behaviour (Karafillakis et al., 2019).
Where HPV vaccines are administered to girls, which is ideal to ensuring protection before an individual is forced into or chooses to become sexually active and thus faces a risk of acquiring a cancer- causing HPV, parental consent and therefore attitudes become essential. Girls with a family member
(e.g., mother, sister, etc.) who has been vaccinated against HPV are much more likely to get vaccinated; the opposite is also true (Ogembo et al., 2014). In many settings, including settings in SSA, males are the ones with greater decision-making and tend to be more conservative, even more so when it comes to their daughter’s sex lives (Poole et al., 2013). Religious beliefs can also play a role: where there are expectations of abstaining from sex until marriage, this often translates into gendered norms and expectations, with women/girls being the ones primary responsible for upholding such rules (i.e., staying pure) (Wilson, 2021).
Because of the great threat vaccine hesitancy poses to reversing progress made in stopping vaccine-preventable diseases (like HPV), a better understanding of factors contributing to it, especially those that are sociocultural in nature, and how to effectively intervene are both needed as soon as possible. Our study looks to fill this gap for our specific context.
List of references
Centers for Disease Control and Prevention (2022, February 1). COVID-19 Vaccinations in the United States. Centers for Disease Control and Prevention. https://covid.cdc.gov/covid-data- tracker/#vaccinations_vacc-total-admin-rate-total
Government of Canada (2022, February 1). COVID-19 vaccination in Canada. Government of Canada. https://health-infobase.canada.ca/covid-19/vaccination-coverage
Karafillakis, E., Simas, C., Jarrett, C., Verger, P., Peretti-Watel, P., Dib, F., De Angelis, S., Takacs, J., Ali, K. A., Pastore Celentano, L., & Larson, H. (2019). HPV vaccination in a context of public mistrust and uncertainty: a systematic literature review of determinants of HPV vaccine hesitancy in Europe. Human vaccines & immunotherapeutics, 15(7-8), 1615–1627. https://doi.org/10.1080/21645515.2018.1564436
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Ngwa, C. H., Doungtsop, B.-C. K., Bihnwi, R., Ngo, N. V., & Yang, N. M. (2021). Burden of vaccine- preventable diseases, trends in vaccine coverage and current challenges in the implementation of the expanded program on immunization: A situation analysis of cameroon. Human Vaccines & Immunotherapeutics, 1–10. https://doi.org/10.1080/21645515.2021.1939620
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Remes, P., Selestine, V., Changalucha, J., Ross, D. A., Wight, D., de Sanjosé, S., Kapiga, S., Hayes, R. J., & Watson-Jones, D. (2012). A qualitative study of HPV vaccine acceptability among health workers, teachers, parents, female pupils, and religious leaders in northwest Tanzania. Vaccine, 30(36), 5363–5367. https://doi.org/10.1016/j.vaccine.2012.06.025
Romo, V. (2021). Unvaccinated People Are 11 Times More Likely To Die of COVID-19, New Research Finds. NPR. https://www.npr.org/2021/09/10/1036023973/covid-19-unvaccinated- deaths-11-times-more-likely
Wilkinson, A., & Leach, M. (2015). Briefing: Ebola – myths, realities, and structural violence. African Affairs, 114(454), 136-148. https://doi.org/10.1093/afraf/adu08
Wilson, R. (2021). HPV vaccine acceptance in West Africa: A systematic literature review. Vaccine, 39(37), 5277–5284. https://doi.org/10.1016/j.vaccine.2021.06.074
World Health Organization. (2019). Ten threats to global health in 2019. World Health Organization. https://www.who.int/news-room/spotlight/ten-threats-to-global-health-in-2019
