Barriers, facilitators of HPV vaccine uptake in Singapore
Young Singaporean women are likely to get themselves immunized against human papillomavirus (HPV) with the motivation to protect their own health, positive information about the vaccine and parental encouragement, as reported in a recent qualitative study.
On the other hand, low risk perception of HPV and cervical cancer, the stigma of connection of HPV and cervical cancer with sexual activity, and concerns about side effects and the high cost of the vaccine create a barrier to vaccine delivery.
“The results showed that to increase uptake of HPV vaccination, raising awareness of HPV vaccination and cervical cancer could be considered,” according to the authors.
Intervention efforts may be directed toward school-based education, extension of education to parents and active participation of healthcare professionals to inform both young women and parents about HPV vaccination, they said.
“In the longer term, a change in policy regarding the administration of the HPV vaccine would be the key to improving uptake of HPV vaccination, such as a significant reduction in the cost of the vaccine, implementing a national school-based programme or making the vaccine compulsory,” they added.
In the study, 40 young women studying in the National University of Singapore (NUS) from various faculties and socioeconomic levels underwent in-depth interviews (IDIs) and joined in focus group discussions (FGDs) that explored facilitators and barriers of HPV vaccination at five levels of the socio-ecological model (SEM): individual, interpersonal, organizational, community and policy.
The median age of the participants was 19.5 years. Most of the women (n=29; 72.5 percent) were unvaccinated, seven were vaccinated, and four had incomplete vaccination. All except one participant who had been vaccinated had the vaccination funded by their parents.
Seven themes emerged as barriers to vaccination: three were perceptual in nature (ie, lack of awareness, lack of perceived risk and concerns about side effects), two were sociocultural (ie, connection with sexual activity and lack of parental support), and the remaining two were logistical (ie, vaccine cost and inconvenience). [Vaccine 2019;doi:10.1016/j.vaccine.2019.08.053]
At the individual level, participants did not seek to be vaccinated because they felt that there was inadequate publicity on HPV and cervical cancer, and the existing efforts were not strong enough to motivate them to change their behaviour. They also held the view that they were not at risk or that cervical cancer was not a frequent or serious disease since it was seldom heard of.
Furthermore, some women expressed that cervical cancer was hardly ever discussed due to being perceived as a ‘taboo’ topic owing to the disease’s link to sexual activity, posing an individual and interpersonal barrier to vaccination. In other words, getting vaccinated puts one at risk of being thought of as sexually active or even promiscuous.
The fact that the young women also listened to their parents, who might not be keen or supportive of HPV vaccination due to the cost and lack of knowledge of the benefit of vaccine, was also a significant interpersonal barrier. Cost and inconvenience, on the other hand, largely represented a barrier on the community and policy levels.
Better to prevent than cure
Meanwhile, participants who had been vaccinated expressed similar views that it was better to take steps to prevent than cure a disease, regardless of their understanding of what cervical cancer was. Most of them cited having been informed by a trusted individual about the safety and efficacy of the vaccine, boosting their confidence in the benefit it conferred.
The young women also admitted that they had mostly been vaccinated due to their parents’ encouragement or facilitation, ranging from vocal suggestions to have their daughters receive the vaccine to making appointments for them and shouldering the cost. This mirrors the theme identified from the nonvaccinated participants earlier, where the lack of parental encouragement was a barrier to vaccination, the authors pointed out.
When asked about how they think vaccine uptake would increase, the participants suggested the following: stepping up awareness of HPV vaccination and cervical cancer, making the vaccine more accessible in terms of cost, and declaring vaccination as compulsory.
“This qualitative study has shown that barriers and facilitators exist at different levels of the SEM to influence vaccine uptake,” the authors said. “The information would also be useful for public health practitioners and policymakers from other countries in Asia.”
In April this year, the Ministry of Health in Singapore started offering free HPV vaccination as part of a national school-based HPV vaccination programme for 13-year-old girls. The vaccination, while not mandatory, is administered on an opt-in basis. [https:// www.channelnewsasia.com/news/singapore/sec-1-female-students-free-hpvvaccine-against-cervical-cancer-11316882]
“Further monitoring and evaluation of vaccine uptake and incidence of HPV-related disease after the programme is more established would be needed,” the authors said.