Reasons for vaccination
Perception of risks and health benefits
Parents reflected on the success of vaccinations in Vietnam in general, with a focus on disease prevention more broadly. As the following quote suggests, some parents participated in the HPV vaccination program less out of fear of HPV infection or cervical cancer per se than from a conviction that vaccination itself is beneficial:
“…Immunization is the best way of prevention. Whatever disease like tuberculosis or measles, immunization is the best. Prevention is better than treatment.”
Parent of fully vaccinated girl, FGD, Year 1, Rural, low uptake commune"
Others voiced health rationales that were specific to fears of cervical cancer:
"“I was advised by the doctor so I took the girl to get vaccination. It is because I saw many people had that awful disease. Most patients with cancer do not survive. That’s what I heard. I also knew that vaccination can prevent the disease ; that is why when hearing about vaccination, I was very happy.”
Parent of fully vaccinated girl, FGD, Year 2, Urban, low uptake commune
"Although health benefits were offered as a reason among participants across all regions, in focus groups in urban areas parents tended to specifically emphasize this point, confirming the importance of vaccination in preventing disease.
Trust in governmental program
Focus group findings also suggested that people were influenced by knowledge that the campaign was a publicly-implemented program, their reasoning grounded in a belief that “government cannot harm people’s health” with the introduction of a given health service or new vaccine.
"“Firstly, it is a government program. Secondly, it is the responsibility of all parents. Those reasons are enough to decide.”
Parent of fully vaccinated girl, FGD, Year 1, Rural, low uptake commune
This kind of statement was more common in the mountainous region, where many parents considered vaccine being delivered through the national health system as their primary reason for vaccination. They believed that they/their girls were selected to participate in the program because the government cared for them.
"“We heard people talking or saying on the loudspeaker that it was a dangerous disease which could lead to death if treatment did not work. Previously, we did not have opportunity to get treatment, so we could only foresee death. Now, the government cared for us, we shall take our daughter to get vaccinated.”
Parent of fully vaccinated girl, FGD, Year 2, Mountain, hard to reach commune
This may be due to the fact that people in mountainous areas, where most ethnic minorities live, receive several special supports from the government. When a government program is launched, they tend to participate in large numbers more so because the program is government sponsored.
Economic benefits
While the cost of HPV vaccination was not the most common motivation, it emerged as a theme in the FGDs with parents of fully vaccinated girls. Particularly among participants from rural areas, there was a tendency to focus on economic benefits (an expensive but freely-delivered vaccine). As the following quote illustrates, they emphasized that, in the context of high rural poverty, the free vaccine helped to increase acceptability.
"For those who are living in the rural area like us, we are still very poor. When we were told that vaccination helped women to prevent diseases, we found that it was really helpful. In fact, in the rural area, we cannot afford to take a child or a family member to the hospital for health care services. So when we heard that information on the loudspeaker and even on television, we found it did bring benefits and we took the girls to get vaccination.
Parent of fully vaccinated girl, FGD, Year 2, Rural, low uptake commune
However, in a larger context of vaccine acceptance, the economic rationale was not a critical factor.
Reasons for non-acceptance of vaccination
Patterns for non acceptance of HPV vaccination reflected in qualitative research followed three principal themes: vaccine safety and side effects, suspicion and misconceptions about the HPV vaccine, and concerns related to the age of the girl and her risk of cervical cancer. The quote below, while touching on vaccine safety and side effects, also shows concern about the newness of the vaccine related to the daughter’s perceived vulnerable age:
"“Generally, I don’t need any more information. However, I worried if there would be any side effect on my daughter’s health [after vaccination]. I understood, but firstly, the vaccine is new. Secondly my daughter is still too young so I don’t want her to receive a new vaccine. Don’t know what will happen to her in the future.”
Parent of non vaccinated girl, SSI, Year 1, Urban, low uptake commune
This quote illustrates the interconnected nature of parent concerns and suggests that multiple issues may be raised when parents are given the opportunity to discuss their rationales in depth.
Another theme that emerged was suspicion and misconceptions about the program or vaccine, sometimes centered on mistrust that a very expensive vaccine was being offered free of charge and therefore may be low quality (“fake medicine”), and at other times expressed as fear that children may be part of a vaccine trial (primarily in the first year).
"“…What that professor said significantly influenced my decision. Working in health sector, he should be very knowledgeable in this issue. His remarks made me concerned, leading me to cancel the second dose[for my daughter]. People said this vaccine is very expensive, priority should go to relatives of ‘insiders’ who are highly ranked officers working in health sector. Secondly, if this vaccine is good, besides the option of having our daughter vaccinated for protection, we also have the choice of not taking it. In our situation, I felt some suspicion as my daughter’s teacher mentioned about various things [about the vaccine], scaring her…”
Parent of non vaccinated girl, SSI, Year 2, Urban, low uptake commune
""“On that day, there was an official from district and commune levels. I also asked questions, but they gave only general answers. They could not answer my question if this vaccine project is a trial or not, and who would take responsibility for the potential effects.”
Parent of non vaccinated girl, SSI, Year 1, Rural, low uptake commune
"If the vaccine is introduced in the whole country then I have no objection, but why only two provinces, that is my concern. I feared that my daughter may be used for experiment; besides, I wonder why only children in grade 6 but not children of other ages? That did not convince me; maybe the vaccine is on trial and the children are used to check the effects of vaccine.”"
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Parent of non-vaccinated girl, SSI, Year 1, Urban, low uptake commune)
Age-related concerns—exposing young adolescent girls to HPV vaccination—were an important reason for refusal among some parents. From the quote below, it appears that not all parents understood that HPV vaccine has greater efficacy if administered prior to the onset of sexual activity. From the point of view of one mother, it was not necessary to administer HPV vaccine at such an early age, and better to wait until the girl reached maturity.
"“From what I have read, I found that girls at this age group have not started sexual activities, so the vaccine would only be effective in five years. After that, the girl should repeat doses each year. My girl is just 12 years old, which means that she will become sexually active in the next six years and will be exposed to the disease then. So I decided that whenever her health is ready, I would allow her to get vaccination. At that time, I believe that the vaccination program is better, so I would volunteer to take my daughter to preventive medical centers for vaccination.”
Parent of non-vaccinated girl, SSI, Year 2, Urban, low uptake commune
For other parents, concerns regarding the daughter’s age center on her perceived vulnerability, and a potential impact on her physical development.
"“In my girl’s case, she is not mature yet. She even has not started menstruation yet. I speak so truthfully to you because you are working in the health sector. You know, I am afraid whether vaccination would affect her natural development. I am afraid so I do not allow the girl to get vaccination.”"
Parent of non-vaccinated girl, SSI, Year 2, Urban, low uptake commune
Active and passive decision-making
Based on analysis of how parents make decisions about HPV vaccination, we conceptualized the process as either a passive decision or active decision according to whether parents sought the advice of others. While the former refers to the group of parents who made the vaccination decision without seeking additional information, the latter includes those who decided after consulting one or more additional sources of information (see Figure 3).
Passive decision-making
Our qualitative findings suggest that passive decision-making occurred frequently during the first year of HPV vaccine implementation, and may have occurred more often in mountainous areas. The quote below illustrates this passive decision-making process:
I told my daughter that this was a deadly disease, and that my family was still in difficulty. As what was stated in the loudspeaker, vaccination was to prevent the girl from this disease when she grew up and got married. If the disease did occur, we could not afford the treatment. So it would be better if she got vaccination to prepare for perfect health in the future when she got married.
Parent of fully vaccinated girl, FGD, Year 2, Mountainous, hard to reach commune
Passive decision-making may prevail when parents participate in the HPV vaccination as a routine response; in the example below, vaccination is just something that one does as a matter of course:
"“…Immunization is the best way of prevention. Whatever disease like tuberculosis or measles, immunization is the best. Prevention is better than treatment.”
Parent of fully vaccinated girl, FGD, Year 1, Rural, low uptake commune
Active decision-making
On the contrary, people in urban areas tended to engage in more active decision-making, seeking additional information, often from individuals or sources outside the vaccination program, as illustrated below:
"“I searched in newspapers and found that although this vaccine was new in Vietnam, its use had been growing in many countries. So when I received the information, I talked to my wife and came to a final decision. I have two daughters, the older has mental problem, so I consider health as the most important issue for my younger girl. In South East Asia, cervical cancer is quite common, so when there is scientific advance in treatment, we, the parents, should create good conditions for our child. We both decided that.”
Parent of fully vaccinated girl, SSI, Year 1, Urban, low uptake commune
"“After the doctor said the vaccine has been circulated in the market for everyone already and passed the trial period, I felt more secure. Plus, my relatives said the vaccine has been used in America so that’s why I agreed to vaccinate my daughter.”
Parent of fully vaccinated girl, SSI, Year 1, Urban, low uptake commune
Media, with both positive and negative messaging, may be particularly influential for Active Decision-makers, as illustrated below:
"“I heard from people and from the radio that this vaccination was dangerous, and this and that bad things and this and that bad things may happen so I was afraid. But then my mother, mother-in-law, and cousins urged that I should take my daughter to get vaccinated, that we were still poor and it was a great and rare chance to get this donation, and that I should take the girl to get vaccinated for good health.”
Parent of fully vaccinated girl, FGD, Year 2, Urban, low uptake commune
"“In my case, when my daughter brought the vaccination invitation from school, I was also afraid. I felt afraid as some people who got rabies vaccine became paralytic after that. Those cases were also shown on television. I also did not know much about this vaccine, what kind of cancer it would prevent, so I was afraid that it might cause side effects like rabies vaccine. After careful consideration, I thought that for such expensive vaccine, which was sponsored and was developed by professional doctors and scientists would be not harmful. So I changed my mind and allowed the girl to get vaccinated. But at first I felt quite confused.”
Parent of fully vaccinated girl, FGD, Year 2, Urban, low uptake commune
The process of active decision-making takes time, as parents seek out additional resources and mull over their decision, as shown below. Parents with residual concerns may also wait to observe any negative consequences among vaccine recipients, before committing to vaccination:
"“…at the beginning I did not allow my daughter to receive vaccination. [However], after about a month, her school and the local health workers patiently invited me over to inform me about the HPV program. The doctors and nurses were very enthusiastic. If I had any questions or concerns or anything was unclear, they clarified these issues very thoroughly. Besides, I have relatives abroad who told me that where she lives now, they provide vaccination for women at the age of 25 instead of 11 years old like in Vietnam. Then, I was much more at ease and agreed to vaccinate my daughter. So, in fact, my daughter received the vaccination one month later than her friends.”
Parent of fully vaccinated girl, SSI, Year 1, Urban, low uptake commune
"“I find that those girls who were vaccinated last year, now they are in 7th grade and their health is still good. Last year, a counseling group visited each household to persuade the parents to have the girls vaccinated. Then the parents found that their girls were still in good health after vaccination. Thus this year, they even took the younger sister to get vaccinated.”
Parent of fully vaccinated girl, FGD, Year 2, Rural, low uptake commune
We found that parents rarely made decisions based on a single factor. As many of the quotes from our qualitative findings demonstrate, parents weighed a host of often interconnected considerations. They employed various strategies to reinforce their decision, including actively seeking further information, getting advice from health professionals or family members (in-country or abroad), or waiting and following other parents’ actions. Though some parents had unresolved concerns about side effects and safety, even after receiving information on HPV vaccination, most decided to accept vaccination based on advice and information from external sources.