In Vietnam, the EPI system has a long history of development and has met with considerable success in reducing the burden of vaccine-preventable diseases. Its strong reputation contributes to a positive attitude in the population toward vaccination in general. The Vietnam HPV vaccine experience suggests that NEPI has succeeded in building trust by demonstrating the effectiveness of vaccination for disease prevention. We found evidence of this in expressions of belief in vaccination in principle, and the identification of government involvement as a rationale for accepting vaccination. Indeed, formative research prior to the vaccine demonstration project found that Vietnamese parents, teachers, health providers, and civic leaders voiced high levels of confidence in the government immunization program [5
]. For the general population in Vietnam, governmental programs are associated with high quality standards and rigor, so they are more likely to participate in these governmental programs rather than in seeking the same service from health providers in the private sector. The delivery of HPV vaccine by commune health center personnel and the additional involvement of local authorities brought credibility to the program and was a demonstration that the program was supported by the government.
In addition to finding common themes for vaccine acceptance between the first and second years of the program, our qualitative findings are also quite consistent with quantitative data from parental surveys conducted from the same vaccine demonstration projectd
. LaMontagne et al. found that Vietnamese parents were motivated to participate in the vaccination campaign by health rationales (92–94%), the involvement of the government (12–32%), the advice of health workers and teachers (3–36%), and to a lesser extent, by economic considerations (13–14%) (Table )e
]. Health rationales were also a strong motivator for mothers participating in an HPV vaccine intent-to-vaccinate study recruited from a hospital in Da Nang [25
]. However, this study was done prior to the availability of HPV vaccine in the Vietnamese market, discussed acceptance of HPV vaccine as an individual health care-seeking decision, and did not explore the principal role government plays as the provider of more than 90% of all vaccinations in the country.
Table 2 Reasons for HPV vaccine acceptance, parents of fully vaccinated girls, 2009–2010 (Adapted)
While health rationales were preeminent, 12% and 20% of survey respondents in year 1 and 29% and 32% in year 2 indicated that the program being run by the government was a motivating factor. This survey response pattern was particularly evident in the mountain and rural regions, where parents were significantly more likely to say they were influenced by the fact that it is a government program (p<.000; data not shown). These findings echo what we observed in the FGDs in the mountain region, where government involvement in the program was a strong motivating factor.
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. However, formative research in Vietnam found that even for non donated vaccine, acceptance is still high as long as the price is affordable [5
]. Moreover, analysis of year 2 survey data by region found no geographic differences in the identification of cost factors as a rationale for vaccine acceptance, calling into question whether economic considerations are more prevalent in some parts of the country than others [20
Rationales for not vaccinating that emerged in our qualitative study—fear of side effects, misconceptions and suspicions about HPV vaccine and the project, and age-related concerns—are also echoed in results from surveys of parents [20
]. Rationales for not participating in the first yearf
were concerns about the safety of HPV vaccine and possible side effects (33% and 6%), concerns about the health impacts of vaccination more generally (32% and 6%), and worries about the newness (15% and 12%) and possibly experimental nature of the vaccine (5% and 18%) (Table ).
Table 3 Reasons for not participating or not participating fully in HPV vaccination, 2009 (Adapted from)
Concerns about safety and vaccine side effects are a common refrain in HPV vaccine acceptability literature [11
] but suspicion about the vaccine and the intentions of HPV program planners (reflected in parents’ concern that children may be part of a vaccine trial) emerged less often. In part, this reflects the preponderance of studies from industrialized settings with strong regulatory systems in place (e.g., US, UK, Australia, and Canada). Indeed, a number of studies from developing countries have reflected concern that HPV vaccines are not well-tested (South Korea), concern over whom the vaccine has been tested on (Ghana), and suspicion over the involvement of foreign entities (India) [29
]. Collectively, these findings suggest that addressing suspicions related to foreign involvement and the difference between demonstration projects (or scale-up) and vaccine clinical trials may be crucial considerations for HPV program planning in developing country settings. The need to involve influential government stakeholders in a visible fashion is another lesson learned from PATH’s experience in Vietnam, and elsewhere [32
While concerns about vaccine impacts on fertility were cited by less than 10% of parents of non-vaccinated girls, the findings from Vietnam echo those from other studies of HPV vaccine acceptability in developing country settings [33
]. More than one third of Chinese parents (38%) cited age as a rationale for not vaccinating [34
] and more than two thirds of Ghanaian respondents (68%) expressed concerns about HPV vaccine impacts on fertility [30
]. Our qualitative findings suggest that worry over the vaccine undermining a girl’s ‘natural development’ and compromising her immature health status may be connected to concerns about compromising her future fertility. These findings suggest that formative research to explore cultural perceptions of adolescent health and development and how conceptions of adolescence as a vulnerable period may impact HPV vaccine uptake could be beneficial in advance of vaccine introduction. They also speak to the need for information, education, and communication efforts that target any perception that young female adolescents are especially vulnerable to negative health effects from vaccination, wherever such perceptions are identified.
With respect to the decision-making process, we identified many active decision-makers—parents who sought out additional information to inform and confirm their vaccination decisions. Indeed, findings from a quantitative study of vaccine acceptability showed that more than four out of five parents reported that they had discussed HPV vaccination with someone prior to their decision in the first year. As the vaccination campaign matured in the second year (and coverage rates reached 97%), there was still more communication and discussion about the program. In this study, 94% of surveyed respondents in Year 2 reported that they had discussed HPV vaccination with someone prior to making a decision [20
]. Moreover, active decision-makers were significantly more likely to accept vaccination than passive decision-makers who made a decision without discussion (data not shown).
The high prevalence of active decision-making in Vietnam is quite consistent with results from the UK, where only 14% of parents based their HPV vaccine decision solely on information provided by the program [35
]. However, that study identified a very intransigent population of active refusers, who, the authors felt, would be unlikely to change their minds despite exposure to additional information [35
]. While these findings may suffer from selectivity bias, if active refusers are more likely to respond to the survey and attend information nights, the findings raise intriguing questions about the ability of vaccine campaigns to change entrenched anti-vaccine attitudes.
The existence of ‘active refuser’ populations who believe that vaccination may have negative, long-term, and unknown side effects is a widespread phenomenon. In the Netherlands, resistance to polio vaccination was sometimes based on religious conviction [36
]. Highly educated parents may resist MMR vaccine on the belief that it ‘impairs the immune system’ [37
]. Similar ‘anti-vaccination’ attitudes have been observed among parents with respect to HPV vaccine in Australia [38
]. Indeed, anti-vaccination attitudes were common enough among parents in Australia that Cooper Robbins and colleagues, employing a conceptual framework similar in many respects to the model we use, identify ‘anti-vaccination’ as a separate decision-making state, distinct from active and passive decision-making. Our qualitative findings, in the context of a very high rate of vaccine uptake, particularly in the second year (97%) and among active decision-makers, suggest that such entrenched anti-vaccine (or anti-HPV vaccine) attitudes are yet to take root in Vietnam.
Our findings about the importance of active decision-making in a developing country setting generate several implications. First, to maximize effectiveness, communication campaigns may need to employ a broad brushstroke, targeting influential figures, teachers, health workers, and other members of the public; regardless of any direct involvement in the program, these individuals may influence uptake indirectly, through informal consultations. The second concerns the possibility that discussion with others may quell vaccine-related concerns and/or generate the perception of broader community support for vaccination. Researchers may want to explore further if and how dialogue facilitates decision-making and contributes to vaccine uptake. Third, program planners would do well to anticipate the need for active decision-making in the scheduling of vaccination campaign activities by providing information well in advance of the scheduled vaccination drive.
Limitations and strengths
Our study, while robust, may have limitations that affect the interpretation of our findings. Even though we have tried for a diverse set of participants, because selection was criteria-based and not random, there could be selection bias among the participants that may over or under-estimate the different factors mentioned as motivators for vaccine acceptance.
We did not sample specifically for equal representation of mothers and fathers, and the sex of the parent was not available for parents of partially- or non-vaccinated girls who participated in a semi-structured interview. Therefore, we could not analyze our results for possible differences between parents. However, previous research about parental decision-making for vaccination in Vietnam indicated that such decisions are made jointly, suggesting that there would be a high concordance between parents’ acceptability, thus reducing the need to study mothers and fathers separately [5
]. Previous HPV vaccine intent-to-vaccinate research among Vietnamese parents by Breitkopf, et al. demonstrated that mothers and fathers largely agreed on their recommendation to accept or not accept a hypothetical offer of HPV vaccine for their daughter [39
Additionally, because so few girls overall were partially-vaccinated and only 3% of the total population did not accept HPV vaccine in year 2, there were too few parents available from these groups to constitute a focus group, necessitating the use of SSIs. While the SSI approach differs from a focus group, the SSI questionnaire content was nearly identical to that explored through the FGD methodology with parents of fully vaccinated girls that there may not have been a loss in substantive content through the two techniques. Even though our analysis utilized a rigorous inductive and iterative process to identify key themes and subthemes, we may have missed key minor voices, especially from parents of partially vaccinated girls, which could have enriched the picture of vaccine acceptability among parents in Vietnam. However, we sought to minimize these limitations by the extensive scope of our sample and thoroughness of our FGD and interview guides with parents, allowing for the broadest range of ideas to come forward during data collection. Additionally, the qualitative research methodology we employed allowed us to explore in greater depth parents’ stated reasons for participating or not participating in the vaccination campaign, to gain a more comprehensive understanding of the decision-making process itself—an in-depth exploration that is not necessarily possible through fixed-response survey questions utilized by quantitative techniques. Our qualitative methods complemented the quantitative surveys conducted among these same populations and they both reinforce/affirm/confirm each other, reflected in the consistency of results from both studies. Lastly, our study was able to confirm acceptability motivators and process by collecting data from parents at two points in time, after each year of vaccinations, which provided information on how HPV vaccine acceptability may have evolved over time as the vaccination program matured.