Depending on where you live, you may remember getting the HPV vaccine in middle school. Maybe you remember hearing adults debating whether or not you should get the shot. Or maybe you have no idea whether it was one of the (likely many, if you live in a WEIRD country) shots you got at an annual checkup. In the early tween years, you may have been more preoccupied with evading gym class or scheming ways to trade your friend for the extra cookie in their lunchbox.
Despite the irrelevance of the term ‘HPV’ to many middle schoolers’ minds, the human papillomavirus is a serious health problem, with its DNA carried by over 291 million women globally.1 HPV, a sexually transmitted infection, is the leading cause of cervical cancer worldwide—studies estimate that it is present in 90% of cases. With cervical cancer as the fourth leading cause of cancer and cancer deaths, this means women faced approximately 620,000 new cancer cases caused by HPV in 2019 alone.1
The Good News?
The HPV vaccine is the most effective method of preventing cervical cancer. The vaccine is cheap, easy, and well-tested. Generally, the HPV vaccine is recommended for girls ages 9 to 13 years old. Although boys can and should also receive the HPV vaccine (as they can spread the disease to female partners and everyone’s increased vaccination may lead to herd immunity), girls’ vaccination has been prioritized, as they are the ones at risk of developing cervical cancer.
Although the full HPV vaccine includes multiple doses, with immunocompromised individuals requiring up to three doses, a 2022 release from the World Health Organization (WHO) concluded that just a single dose of the HPV vaccine still significantly reduces the risk of cervical cancer.2
All of this being said, although HPV vaccines are highly effective and beneficial, they should not be considered as a replacement for other important cervical cancer prevention measures (like continued screening).
A Concerning Picture
Despite the value of HPV vaccines, uptake among young girls remains considerably lower than the WHO target of 90%.3 This is especially true in many low and middle-income countries worldwide. In Kenya, for example, cervical cancer is the leading cause of cancer-related deaths among women, resulting in approximately 3,400 deaths annually.4 With this high level of risk in mind, the WHO introduced a new vaccination schedule in Kenya in 2019 targeting 10-year-old girls through treatment at health clinics and hospitals.5 Unfortunately, as of 2021, only 31% of the target group had been vaccinated.3
In a recent behavioral science hackathon-style event, my colleagues and I proposed a two-part, behavioral science-informed intervention that combines direct messaging and building peer networks specific to rural Kenya.
- A pre-existing and funded HPV vaccination scheme (making it much easier to increase vaccination rates)
- Low rates of vaccination (increasing potential impact for change)
- Low rates of girls’ secondary school enrollment, where vaccines are typically distributed (we wanted to target those not in school for the most impact)6
What are the Social & Behavioral Barriers to Increasing HPV Vaccination?
Misinformation & Skepticism
As we all know from the past few years, misinformation can play a huge role in parents’ decisions about whether or not to vaccinate their children. After COVID-19, government and healthcare providers may have growing suspicion and distrust of vaccination programs. Some even attribute infertility to the vaccine, which fuels HPV vaccination hesitancy and refusal. As one teacher interviewed in rural Kenya stated, “Maybe the government wants to do something for the girls so that they don’t have partners at school… They are being injected so that they don’t become pregnant at school.”7
There’s also a serious lack of knowledge: in Kenya, 40-60% of parents don’t know about the link between HPV and cervical cancer.8 This makes it hard to grasp the importance of the vaccine, especially when many parents also don’t understand the vaccine’s safety.
Fears About Promiscuity
Since HPV is an STD, many parents think their girls are too young to be vaccinated and fear that pre-pubertal HPV vaccination may encourage promiscuity.9 Religious leaders are an integral part of these communities and fueled by misinformation, some Catholic church doctors have warned Kenyan parents that vaccinating daughters could promote sexual promiscuity.6
How Can We Craft a Theoretical Solution Using Behavioral Science Techniques?
To address these fears, combat misinformation, and educate the public on the importance of the HPV vaccine, my team and I designed a two-part intervention strategy. Our approach targets the parents of young Kenyan girls who aren’t enrolled in school. The intervention, shaped by behavioral science techniques, utilizes the support of the health ministry, public contact information records, and qualified health educators from organizations like UNICEF. The first part of the intervention focuses on educating the parents directly via text messages, while the second part emphasizes building peer networks and empowering community members to educate each other.
Part One: SMS Text-Based Intervention
Why Use Text Messages to Communicate Vaccine Information?
- 59.2% of people in rural Kenya lack internet10
- 91% of people in Kenya have phones, most of which can receive SMS texts but can’t access the internet11
- 83% of rural Kenyans are considered literate12
- Kenya has over 50 languages spoken12
With limited access to communicating with others on the internet, text messages can reach a broad audience. Many texting education and outreach platforms like Artist have the capacity to translate into a plethora of languages, which would be especially helpful in a diverse place like Kenya. These programs also provide an opportunity for recipients to engage with the messages by allowing them to ask questions or answer multiple-choice prompts. This kind of engagement is hugely influential in encouraging long-term behavior change.
Information to Communicate
These text reminders, clearly labeled as from The Ministry of Health, would educate parents on how, where, and when to get their daughters the vaccine. Messages would emphasize the safety, ease, and free access to the vaccine, while also underscoring the importance of the vaccine in several ways. Conscious of the key barrier to vaccination (the stigma currently attached to the shots), this outreach campaign would tackle the misinformation and social and psychological bias against the vaccine, including the ones below.
Using Behavioral Science to Impact Behavior
Authority Bias: When information comes from a figure of authority, people are more likely to believe it and comply. As previously mentioned, these texts will be from The Ministry of Health or another trusted leader and clearly labeled as such.
Framing: Since the way we word things matters, messaging will be focused on promoting lifelong protection. Instead of focusing on HPV or STD transmission (which is important but in this case hindered by overwhelming social stigma), messaging should focus not only on the spread of HPV but also on preventing cancer and keeping children safe (because who could disagree with that?). Because cervical cancer can cause infertility in women, and because fertility is so highly valued in this region, the messaging will also emphasize that this vaccine protects the girls’ ability to become a mother and support future generations.
Social Norms: Social norms, which exist in both descriptive (what is done) and injunctive (what should be done) forms, are a powerful tool in shaping perceptions of acceptable behavior. When people are made aware that the majority of others like them are behaving a certain way, they’re more likely to comply (remember the famous hotel towels example?).
In this case, social norms work in our favor: the majority of girls in rural Kenya are being vaccinated. Parents should be aware that this behavior is normal, expected, and most of all, safe. We can even emphasize the similarities these parents share with the other parents who are vaccinating their daughters (such as having same-age children, sharing similar values, or living in nearby neighborhoods). Violating an injunctive norm has an even stronger effect on the psyche. That’s why framing the vaccine as a moral obligation to children is key: we all should be protecting each other and caring for the vulnerable.
Metaphors: If you recall from the description of the key social barriers, one way stigma against STD vaccination and misinformation is perpetuated is through the church. Although targeting misinformation among pastors and church elders is possible, a less provocative and more empowering route may be to encourage the parents (the ultimate decision-makers) directly, appealing to their religious and cultural values and assuring them that vaccinating their daughters does, in fact, align with the church.
Metaphors, which we conveyed through images and language choice, represent socially relevant concepts and themes such as life protection, fertility, community, and preservation tying together vaccination and church teachings. Depicting the shot as a shield or a spear emphasizes the power of the vaccine to defend, and the language of vitality and growth, along with the images of flowers and nature, both represent daughters’ fragile fertility guarded by the syringe.
We planned to incorporate these metaphorical images into the texting campaigns and ideally display some in health centers, helping reach individuals who are illiterate or can’t receive the photo texts. Images would underscore the collectivist values prevalent in Kenya, which emphasize protecting the interests of the group over the individual. Here’s an example of some of the visual metaphors we generated (thanks, ChatGPT).
Here, a mother (who ultimately holds the power to vaccinate her daughter) is depicted as a warrior, guarding the young girls playing in the churchyard behind her. Instead of a spear, the defense weapon of choice is a syringe. With the backdrop of the church, it’s clear that to protect innocent children, one must be prepared to make sacrifices and be well-armed (or in this case, get a shot in the arm).
In our proposed text content, we drew on other behavioral strategies (like the spacing effect, to have messages come in different intervals, and the availability heuristic, making the stats on safety and accessibility easy to remember) to best encourage engagement and promote lasting change. A text drawing on social norms might read “Hey! Did you know that 90% of parents of preteen girls in Nyanza approve of the cancer-preventing HPV vaccine? Be part of the solution: one shot today, community protection for all of tomorrow.” Hopefully, with enough information presented in a tactful way, parents will understand the urgency for action.
behavior change 101
Start your behavior change journey at the right place
We used the following prompt: “Please provide an image of an African mother warrior, armed with a vaccine, who is protecting young children with the background of a church.”
Here, a mother (who ultimately holds the power to vaccinate her daughter) is depicted as a warrior, guarding the young girls playing in the churchyard behind her. Instead of a spear, the defense weapon of choice is a syringe. With the backdrop of the church, it’s clear that to protect innocent children, one must be prepared to make sacrifices and be well-armed (or in this case, get a shot in the arm).
In our proposed text content, we drew on other behavioral strategies (like the spacing effect, to have messages come in different intervals, and the availability heuristic, making the stats on safety and accessibility easy to remember) to best encourage engagement and promote lasting change. A text drawing on social norms might read “Hey! Did you know that 90% of parents of preteen girls in Nyanza approve of the cancer-preventing HPV vaccine? Be part of the solution: one shot today, community protection for all of tomorrow.” Hopefully, with enough information presented in a tactful way, parents will understand the urgency for action.
Part Two: Peer-Led Intervention
Although we have high hopes for the text-based outreach program, there are still many people who don’t have phones, can’t read, or, let’s face it, simply won’t care about the incoming messages, even if they come from a source like the Ministry of Health. Peer workshops provide the opportunity to reach these people and facilitate a safe space for discussion, as well as deepen vaccine commitment and confidence for those who received the messages.
Developing Peer Workshops
Those who have interacted with the text messages would receive an invitation to sign up for a community-workshop leader position. These leaders, through in-person communication, could reach those who couldn’t receive or were ignoring the text messages. Similar to the first part of the intervention, the call to action would be framed around collectivist values to communicate the importance of coming together and protecting each other through information. Initial workshops would allow a safe space for the community to express their main fears about the vaccine and would provide a platform to certified health educators to address the main misconceptions. Participants could become trained as peer mentors to educate others about the HPV vaccine and build networks within their communities.
This type of grassroots approach is not new: peer-based interventions are well tested and have been proven effective in changing health-related behaviors.13 Although authoritative dissemination of information (coming from doctors, governments, or other officials) is important and influential, getting the ‘ordinary’ folks involved can influence people in a way that authority figures can’t. In fact, meta-analyses show that it is most effective to pair expert-based approaches with peer-based learning strategies.14,15 In an age of cynicism and skepticism, recommendations coming from a trusted friend, relative, or neighbor may generate more momentum than any mainstream advertising campaign ever could.
Next Steps
It’s important to recognize that this is a theoretical intervention strategy. Although this two-part strategy is based on region-specific research and well-documented behavior change techniques, it will remain a theoretical intervention until tested. Not all interventions end up succeeding in the real world. There may be other barriers we missed, new obstacles may arise, or the approach may lack any kind of scalability. What matters, though, is that we continue to research, design, test, and ultimately solve these kinds of global health crises, whether they’re at home or far away. Because everyone deserves protection.
Thank you to Sorana Bucseneanu, Taoyu Chen, Wenmiao Jin, Yeo Jin Koo, and Muh Zulfajri Shadiq Taswin for their contributions to this theoretical solution we developed when competing in the Nudgeathon 2024.
